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TRANSACTIONS 



OF THE 



American Orthopedic Association 

Seventeenth Session 
Held at Washington May 12^ 7J, and 14^ igoj 



VOL. XVI 



American Journal of Orthopedic Surgery 

VOL. i^H.. ;:;.;.. ,>: .\. (-, ; ;\.v.V\Y 



PUBUSHED BY THE ASSOCIATION 
190S 



LIST OP OFFICERS. 

DBlbctkd Hat 14, 1908.] 



R. H. SAYRE, M.D. 

F{ce4Ptc0fiimt0. 
J. E. GOLDTHWAIT, M.D. G. G. DAVIS, M.D. 

E. G. BRACKETT, M.D. 

JOHN RIDLON, M.D. 
92 State Street, Chicago. 

00mtnitUt on flUwibtxsifif* 
(Not yet appointed.) 

Sxenttibe Committee. 
The President, the Treasurer, and the Secretary. 

Semjiotstj l^tAIication Committee. 
JOHN DANE, M.D. (Chairman). L. A. WEIGEL, M.D. 

t^UtxAtt of Sxecutibe Committee^ Congtens of Slmetfcan 

W. R. TOWNSEND, M.D. 
AUermUe: R. W. LOVETT, M.D. 



LIST OP PRESIDENTS. 



1887. V. P. GIBNEY, M.D. 

1888. NEWTON M. SHAFFER, M.D. 

1889. E. H. BRADFORD, M.D. 

1890. DE FOREST WILLARD, M.D. 

1891. A. B. JUDSON, M.D. 

1892. BENJAMIN LEE, M.D. 

1893. A. J. STEELE, M.D. 

1894. A. M. PHELPS, M.D. 

1895. JOHN RIDLON, M.D. 

1896. ROYAL WHITMAN, M.D. 

1897. SAMUEL KETCH, M.D. 

1898. R. W. LOVETT, M.D. 

1899. W. R. TOWNSEND, M.D. 

1900. H. M. SHERMAN, M.D. 

1901. A. J. GILLETTE, M.D. 

1902. H. AUGUSTUS WILSON, M.D. 

1903. L. A. WEIGEL, M.D. 



LIST OP MEMBERS. 



1903. Baldwin, S. C, M.D. Orthopedic Surgeon to the Holy 
Cross Hospital, Salt Lake City, Utah; Surgeon to the S. L. & O. 
R.R. 

1901. Bartow, Bernard, M.D. Clinical Professor Ortho- 
pedic Surgery, Medical Department, University of Buffalo; Or- 
thopedic Surgeon, Children's Hospital; Orthopedic Surgeon, 
Erie County Hospital; Consulting Orthopedic Surgeon, Bi^alo 
General Hospital. 481 Delaware Avenue, Buffalo, N.Y. 

1892. Blanchard, Wallace, M.D. Attending Orthopedic 
Surgeon to the Home for Destitute Crippled Children. 34 E. 
Monroe Street, Chicago. 

1889. Brackett, E. G., M.D. Assistant Surgeon to the 
Children's Hospital. 166 Newbury Street, Boston. 

♦1887. Bradford, E. H., M.D. Visiting Surgeon to the 
Children's and the Good Samaritan Hospitals; Professor of 
Orthopedic Surgery in Harvard Medical School. 133 Newbury 
Street, Boston. 

1889. BuRRELL, Herbert L., M.D. Visiting Surgeon to 
the Boston City Hospital; Visiting Surgeon to the Children's 
Hospital; Professor of Clinical Surgery, Harvard University. 
22 Newbury Street, Boston. 

1891. Cook, Ansell G., M.D. Visiting Surgeon to the Hart- 
ford Hospital; Consulting Surgeon to Litchfield County Hospitid. 
340 Farmington Avenue, Hartford, Conn. 

1893. CooLiDGE, Frederic S., M.D. Demonstrator of 
Surgical Appliances in Rush Medical College; Professor of Ortho- 
pedic Surgery, Chicago Post-graduate Medical College; Attend- 
ing Orthopedic Surgeon to the St. Luke's and St. Elizabeth's 
Hospitals; Attending Physician to Children, Presbyterian Hos- 
pital. 103 State Street, Chicago. 

1895. Dane, John, M.D. Junior Assistant Surgeon to the 
Children's Hospital; Assistant Surgeon to the West End Infant 
Hospital. 29 Marlborough Street, Boston. 

1897. Davis, Gwiltm G., M.D. Univ. of Penna. and Goet- 
tingen, M.R.C.S. Eng. Surgeon to the Philadelphia Orthopedic, 

*Oriflrlnal Member. 



iv LIST OF MEMBERS. 

Episcopal, and St. Joseph's Hospitals; Assistant Professor of 
Applied Anatomy, University of Pennsylvania. 255 South Six- 
teenth Street, Philadelphia. 

1900. Elliott, George R., M.D. Orthopedic Surgeon to 
Montefiore Home for Chronic Invalids. 48 East Twenty-sixth 
Street, New York. 

1902. FiTZHUGH, P. Henry, M.D. Instructor in Orthopedic 
Surgery, New York Polyclinic; Chief of Clinic and Instructor in 
Orthopedic Surgery, Cornell Medical College; First Assistant 
Surgeon in New York State Hospital for Crippled and Deformed 
Children. 36 West Thirty-fifth Street, New York. 

♦1887. Foster, Charles C, M.D. Orthopedic Surgeon to 
the Cambridge Hospital; Visiting Physician to the Avon Home 
for Children; Visiting Physician to St. Luke's Home for Children. 
8 Elmwood Avenue, Cambridge, Mass. 

1901. Freiberg, Albert H., M.D. Professor of Orthopedic 
Surgery in the Laura Memorial Women's Medical College; Ortho- 
pedic Surgeon to the Cincinnati, Presbjrterian, and Jewish Hos- 
pitals. 706 Walnut Street, Cincinnati, Ohio. 

1899. Galloway, H. P. H., M.D. Surgeon to the Toronto 
Orthopedic Hospital; Orthopedic Surgeon to the Toronto Western 
Hospital; Orthopedic Surgeon to Grace General Hospital, To- 
ronto. 12 East Bloor Street, Toronto, Canada. 

♦1887. Gibney, V. P., M.D. Clinical Professor of Orthopedic 
Surgery in the CoUege of Physicians and Surgeons, Medical De- 
partment of Columbia University; Surgeon-in-chief to the New 
York Hospital for Ruptured and Crippled; Orthopedic Surgeon 
to the Nursery and Children's Hospital and to the Montefiore 
Home and Hospital, New York. 16 Park Avenue, New York. 

♦1889. Gillette, Arthur J., M.D. Professor of Orthopedic 
Surgery in the Minnesota State University; Orthopedic Surgeon 
to St. Luke's, St. Joseph's, Bethesda, City and County Hospitals, 
and the St. Paul Free Dispensary, and Consulting Orthopedic 
Surgeon to Asbury Hospital; Surgeon-in-charge of Minnesota 
State Hospital for Crippled and Deformed Children. 301 Pleas- 
ant Avenue, St. Paul, Minn. 

1892. GoLDTHWAiT, JoEL E., M.D. Orthopedic Surgeon to 
Carney Hospital; Consulting Orthopedic Surgeon to the Massa- 
chusetts General and the New England Hospitals. 372 Marl- 
borough Street, Boston. 

1892. Griffiths, J. D., M.D. Lieutenant Colonel and Medical 
Director First Brigade, National Guard of Missouri; President 
of the Association of Military Surgeons of the U.S.; Surgeon to 

*Ori«rinal Member. 



LIST OF MEMBERS. T 

St. Joseph's Hospital, Kansas City; Consulting Surgeon to the 
German Hospital, Kansas City; Consulting Surgeon to the Kan- 
sas City, Fort Scott, and Memphis R.R. South-west comer Ninth 
and Grand Avenue, Kansas City, Mo. 

1898. Hoffmann, Phil., M.D. Clinical Lecturer on Ortho- 
pedic Surgery in the Medical Department, Washington Univer- 
sity; Chief of the Orthopedic Clinic at St. John's Hospital. 705 
North Channing Avenue, St. Louis, Mo. 

1899. Hopkins, W. Barton, M.D. Visiting Surgeon to the 
Pennsylvania Hospital. 1904 South Rittenhouse Square, Phila- 
delphia. 

1893. HosMER, A. B., M.D. Orthopedic Surgeon to St. Luke's 
Hospital. 103 State Street, Chicago. 

♦1887. JuDSON, A. B., M.D. Orthopedic Surgeon to the Out- 
patient Department of the New York Hospital. 1 Madison 
Avenue, New York. 

♦1887. LovETT, Robert W., M.D. Surgeon to the Infant's 
Hospital; Assistant Surgeon to the Children's Hospital; Surgeon 
to the Peabody Home for Crippled Children. 234 Marlborough 
Street, Boston. 

1893. McCuRDY, Stewart Le Roy, A.M., M.D. Orthopedic 
Surgeon to the Presbyterian Hospital and East End Dispensary; 
Professor of Anatomy and Oral Surgery, Pittsburg Dental College; 
Dean of Pittsburg School of Anatomy. 515 Pennsylvania 
Avenue, Pittsburg, Pa. 

1889. McKenzie, B. E., B.A., M.D. Surgeon to the Toronto 
Orthopedic Hospital; Orthopedic Surgeon to the Grace General 
Hospital; Associate Professor of Clinical Surgery, Ontario Medi- 
cal College for Women. 12 East Bloor Street, Toronto, Canada. 

1901. McKiM, Smith Hollins, M.D. House Surgeon to the 
Hospital for the Relief of Crippled and Deformed Children; 
Chief of Clinic to the Professor of Orthopedic Surgery, University 
of Maryland. 2000 N. Charles Street, Baltimore, Md. 

1889. Myers, T. Halsted, M.D. Attending Orthopedic 
Surgeon to St. Luke's and New York Foundling Hospitals; 
Attending Surgeon to the New York Orthopedic Dispensary; 
Consulting Surgeon to St. John's Riverside Hospital, Home of the 
Annunciation, and New York Lying-in Hospital. 24 West 
Fiftieth Street, New York. 

♦1887. Packard, George B., M.D. Professor of Orthopedic 
Surgery in the Denver College of Medicine; Orthopedic Surgeon 

•Original Member. 



yi LIST OF MEMBERS. 

to the Arapahoe County Hospital. 732 Fourteenth Street, Den- 
ver. 

1899. Painter, Charles F., M.D. Instructor in Orthopedic 
Surgery at Tufts Medical School; Visiting Surgeon to the House 
of the Good Samaritan; Assistant Orthopedic Surgeon to the 
Carney Hospital. 372 Marlborough Street, Boston. 

♦1887. Park, Roswell, M.D. Professor of Surgery in the 
Medical Department of the University of Buffalo; Surgeon to 
the Buffalo General Hospital; Consulting Surgeon to the Fitch 
Accident Hospital and the Buffalo Eye and Ear Infirmary. 510 
Delaware Avenue, Buffalo, N.Y. * 

1900. Peckham, Frank E., M.D. Orthopedic Surgeon to 
the Rhode Island Hospital. 266 Benefit Street, Providence, R.I. 

1901. Pegram, John C, Jr., M.D. Orthopedic Surgeon to 
St. Joseph's Hospital and to the Rhode Island Catholic Orphan 
Asylum; Orthopedic Surgeon to the Rhode Island Hospital; 
Consulting Surgeon to the Butler Hospital for the Insane; Dem- 
onstrator of Anatomy, Brown University. 277 Benefit Street, 
Providence, R.I. 

1901. Porter, John L., M.D. Professor of Orthopedic Sur- 
gery, College of Physicians and Surgeons (Medical School of Uni- 
versity of Illinois); Assistant Attending Orthopedic Surgeon, 
Home for Destitute Crippled Children; Attending Orthopedic 
Surgeon, St. Luke's Dispensary. 103 State Street, Chicago. 

♦1887. RiDLON, John, M.D. Professor of Orthopedic Surgery 
in the North-western University Medical School and North-west- 
em University Women's Medical School; Senior Attending Ortho- 
pedic Surgeon to St. Luke's Hospital and Michael Reese Hospital; 
Orthopedic Surgeon to the Wesley Hospital -and the Evanston 
Hospital; Surgeon-in-charge of the Home for Destitute Crippled 
Children; Orthopedic Surgeon to the Chicago Hospital School; 
Consulting Orthopedic Surgeon to the Mary Thompson Hospital 
for Women and Children. 92 State Street, Chicago. 

1903. Riely, Compton, M.D. House Surgeon at the Hospital 
for the Relief of Crippled and Deformed ChSdren of Baltimore; 
Chief of Orthopedic Clinic to the University of Maryland; Radi- 
ographer to the Maryland University Hospital, 2000 North 
Charles Street, Baltimore, Md. 

1903. RuGH, J. Torrance, M.D., A.B. Demonstrator of 
Orthopedic Surgery in the Jefferson Medical College; Assistant 
Orthopedic Surgeon to the Jefferson Medical College Hospital. 
1616 Spruce Street, Philadelphia. 

♦1887. Sayre, Reginald H., M.D. Clinical Professor of 
Orthopedic Surgery in the University and Bellevue Hospital 

* Driflrinal Member. 



LIST OF MEMBERS. vii 

Medical College; Orthopedic Surgeon to the Outdoor Depart- 
ment of the Bellevue Hospital; Consulting Surgeon to the Hack- 
ensack (N.J.) Hospital; Consulting Surgeon to the Hospital for 
Sick Children, Newark, N.J. 9 East Forty-fifth Street, New 
York. 

♦1887. ScHAPPS, John C, M.D. Pony, Mont. 

♦1887. Shaffer, Newton M., M.D. Surgeon-in-chief to 
the New York State Hospital for the Care of Grippled and De- 
formed Children; Professor of Orthopedic Surgery, Cornell Uni- 
versity Medical College; Consulting Orthopedic Surgeon to St. 
Luke's and Presbyterian Hospitals; Consulting Surgeon to the 
New York Infirmary for Women and Children. 28 East Thirty- 
eighth Street, New York. 

1896. Shands, a. R., M.D. Professor of Orthopedic Surgery 
in the Medical Department of Columbia University; Assistant 
Physician-in-charge of General Diseases at Emergency Hospital 
and Central Dispensary; Surgeon-in-charge of Orthopedic De- 
partment Emergency Hospital and Centr^ Dispensary; Attend- 
ing Physician to Newsboys' Home and Children's Aid Society. 
1319 New York Avenue, Washington, D.C. 

1889. SHERBiAN, ELiRRT M., A.M., M.D. Orthopedic Sur- 
geon to the Children's Hospital, San Francisco; Clinical Profes- 
sor of Orthopedic Surgery in the Medical Department of the 
University of Califomia. 1303 Van Ness Avenue, San Francisco. 

1902. Spellissy, Joseph M., M.D. Out-patient Surgeon at 
the Pennsylvania Hospital; Assistant Surgeon at the Orthopedic 
Hospital and at the Orthopedic Department of the University Hos- 
pital; Visiting Surgeon at St. Joseph's and the Methodist Hospitals. 
110 South Eighteenth Street, Philadelphia. 

1900. Starr, Clarence L., M.D. Orthopedic Surgeon to 
Hospital for Sick Children; Registrar to Toronto General Hos- 
pital; Demonstrator of CliniciJ Surgery in Medical Faculty, 
University of Toronto. 95 Bloor Street, West, Toronto, Canada. 

♦1887. Steele, A. J., M.D. Professor of Orthopedic Surgery 
in the Medical Department of Washington University; Ortho- 
pedic Surgeon to the Martha Parsons Children's Hospital and 
to the Missouri Baptist Sanitarium. 2825 Washington Avenue, 
St. Louis. 

♦1887. Taylor, Henry Ling, M.D. Professor of Orthopedic 
Surgery and Attending Surgeon to the New York Post-graduate 
School and Hospital; Assistant Surgeon to the Hospital for the 
Ruptured and Crippled; Consulting Orthopedic Surgeon to the 
State Epileptic Colony, Sonyea, N.Y. 125 West Fifty-eighth 
Street, New York. 

1897. Taylor, Robert Tunstall, B.A., M.D. Surgeon-in- 

•Original Member. 



viii LIST OF MEMBERS. 

charge of the Hospital for Crippled Children; Clinical Professor 
of Orthopedic Surgery, University of Maiyland; Orthopedic Sur- 
geon to the University Hospital in Baltimore. 2000 Maryland 
Avenue, Baltimore, M.D. 

1892. Taylor, William J., M.D. Attending Surgeon to the 
Orthopedic Hospital and Infirmary for Nervous Diseases and to 
St. Agnes' Hospital; Consulting Surgeon to the West Philadelphia 
Hospital for Women. 1825 Pine Street, Philadelphia. 

1892. Thorndike, Augustus, M.D. Surgeon to Good Samar- 
itan Hospital; Assistant Surgeon to West End Infant Hospital 
and Junior Assistant Surgeon to Children's Hospital. 601 Beacon 
Street, Boston. 

1889. TowNSEND, W. R., M.D. Professor of Orthopedic Sur- 
gery in the New York Polyclinic; Associate Surgeon to the Hos- 
pital for Ruptured and Crippled, New York; Visiting Surgeon 
to Randall's Island and Bayonne Hospitals; Consulting Ortho- 
pedic Surgeon to the French Hospital. 125 West Fifty-eighth 
Street, New York. 

1901. Waterman, J. Hilton, M.D. Instructor in Orthopedic 
Surgery in the New York Polyclinic Medical School and Hospital; 
Clinical Assistant in the Hospital for the Relief of the Ruptured 
and Crippled. 50 West Fifty-first Street, New York. 

1889. Wbigel, Louis A., M.D. Professor of Orthopedic 
Surgery in the Medical Department of Niagara University, Buf- 
falo; Orthopedic Surgeon to Rochester City Hospital and Out- 
patient Department; Consulting Orthopedic Surgeon to Provi- 
dent Dispensary. 209 East Avenue, Rochester, N.Y. 

1890. Whitman, Royal, M.D. Instructor in Orthopedic 
Surgery and Chief of the Orthopedic Division of the Vanderbilt 
Clinic in the College of Physicians and Surgeons; Adjunct Pro- 
fessor of Orthopedic Surgery in the New York Polyclinic; Asso- 
ciate Surgeon to the Hospital for Ruptured and Crippled, New 
York. 283 Lexington Avenue, New York. 

*1887. Willard, De Forest, M.D. Clinical Professor of Or- 
thopedic Surgery in the University of Pennsylvania; Surgeon to 
the Presbyterian Hospital; Consulting Surgeon to the White 
Cripples' Home, the Colored Cripples' Home, and the Home for 
Incurables, Philadelphia; Consulting Surgeon to the New Jersey 
State School for Feeble-minded Children. 1818 Chestnut Street, 
Philadelphia. 

1899. Wilson, C. W. 55 Union Avenue, Montreal. 

1891. Wilson, H. Augustus, M.D. Clinical Professor of 
Orthopedic Surgery in the JefiFerson Medical College; Professor 
of General and Orthopedic Surgery in the PhiladelpUa Polyclinic 
and College for Graduates in Medicine; Consulting Orthopedic 
Surgeon to the Kensington Hospital for Women and to the Phila- 
delphia Lying-in Charity. 1611 Spruce Street, Philadelphia. 

* Original Member. 



LIST OF MEMBERS. ix 

1890. Young, James K., M.D. Professor of Orthopedic Sur- 
gery, Philadelphia Polyclinic; Clinical Professor of Orthopedic 
Surgery in the Woman's Medical College; Assistant Orthopedic 
Surgeon to the Hospital, University of Pennsylvania; Instruc- 
tor in Orthopedics in University of Pennsylvania; Surgeon to 
the Home for Crippled Children; Orthopedic Surgeon, Hospital 
of the Good Shepherd, Radnor. 222 South Sixteenth Street, Phil- 
adelphia. 



HONORARY MEMBERS. 



1891. EDMUND ANDREWS, M.D., 65 Randolph Street, 
Chicago, 111. 

1893. O. LANNELONGUE, Professeur it la Faculty de M^decine 
de Paris (Chaire de Chirurgie); Membre de FAcad^mie 
de M^decine; Chirurgien de THdpital Trousseau k Paris, 
et D6put6 au Parlement Fran^ais, et President de TAs- 
sociation G4n6rale de M^decine de France. 3 Rue 
Franyois I., Paris* 

1897. BENJAMIN LEE, M.D., Secretary of the State Board 
of Health of Pennsylvania. Crozer Building, 1420 
Chestnut Street, Philadelphia, Pa. 

1890. WILLIAM MACEWEN, M.D., LL.D., Professor of Clini- 
cal Surgery and Surgeon to the Glasgow Royal Infirmary; 
Surgeon to the Royal Hospital for Sick Children. 3 
Woodside Crescent, Glasgow, Scotland. 

1900. JAMES E. MOORE, M.D., Professor of Qinical Surgery 
and Orthopedic Surgery in the University of Minnesota; 
Orthopedic Surgeon to St. Mary's Hospital; Consulting 
Surgeon to the North-western Hospital for Women and 
Children. 802 Da3rton Building, Minneapolis, Minn. 



CORRESPONDING MEMBERS. 



■LXCTBD 

1892. Dr. M. BILHAUT, R^dacteur en Chef des Annales d'Or- 
thop^die et de Chirurgie pratiques; Chirurgien des En- 
fants de THdpital International. 5 Avenue de rOp6ra, 
Paris, France. 

1903. A. CODIVILLA, M.D., Professore incaricato di Ortopedia 
nella R. UniversitJl, Direttore dell' " Istituto Ortopedico 
Rizzoli, zu Bologna." 

1894. Dr. JULIUS DOLLINGER, ausserordentlich-oflfent- 
licher Professor fur Orthopadie an den koni^. ungar- 
ischen Universitat in Buda-Pest, Operateur und diri- 
girender Oberarzt der chir. Abtheilung im Spitalls der 
Barmherzigen Briider in Buda-Pest; Mitglied des Land- 
essanitatsrathes; Mitglied des Landesunterrichtsrathes; 
Mitglied mehrer wissenschaftlichen Gesellschaften und 
Vereine. Buda Pest (Ungam), Rerepescher Str. 52. 

1890. Dr. a. HOFFA, Geh. Medicinalrath' a. o. Professor an der 
Universitat Berlin; Correspondirendes Mitglied der 
Socidt6 de P^diatrie de Paris, Berlin. 

1890. ROBERT JONES, F.R.C.S. Edin., Honorary Surgeon, 
Royal Southern Hospital. 11 Nelson Street, Great 
George Square, Liverpool, England. 

1899. C. B. KEETLEY, F.R.C.S. Eng., Senior Surgeon to the 
West London Hospital; Hon. Treasurer British Ortho- 
pedic Society. 66 Grosvenor Street, W., London, Eng. 

1890. Dr. E. KJRMISSON, Professeur agr6g4 de la Faculty 
de M^decine; Chirurgien del'Hdpital des Enfants Assists. 
27 Quai d'Orsay, Paris, France. 

1890. Dr. SIGFRIED LEVY, Superintending Surgeon of the 
Society for the Relief of Crippled and Mutilated Chil- 
dren, Copenhagen. 135 Gothersgade, Copenhagen, Den- 
mark. 

1892. ERNEST MUIRHEAD LITTLE, F.R.C.S. Eng., Sur- 
geon to the National Orthopedic Hospital. 40 Seymour 
Street, Portman Square, London, England. 

1889. . Dr. ADOLF LORENZ. IX. Gamisongasse 3 (Garelli- 
ho£F), Vienna, Austria. 

1889. HOWARD MARSH, F.R.C.S. Eng., Senior Assistant 
Surgeon and Lecturer on Surgery, St. Bartholomew's 
Hospital; Consulting Surgeon, Hospital for Sick Chil- 



OORRESPONBING MEMBERS. xi 

dren, and Alexandra Hospital for Hip Disease. 30 
Bruton Street, W., London, England. 

1890. EDMUND OWEN, M.B., F.R.C.S., Surgeon to and Joint 
Lecturer on Surgery at St. Mary's Hospital; Senior 
Surgeon to the Hospital for Sick Children, Great Or- 
mond Street, 64 Great Cumberland Place, W., London, 
England. 

1892. ROBERT WILLIAM PARKER, M.R.C.S. Eng., Senior 
Surgeon East London Hospital for Children; Surgeon 
German Hospital, Dalston. 13 Welbeck Street, W., 
London, En^and. 

1890. PAUL RjfeDARD, M.D., Laur^at de I'lnstitute; Ancien 
' Chef de Clinique chirurgicale de la Faculty de M^decine 
de Paris; Chirurgien du Dispensaire Furtado-Heine. 
3 Rue de Turin, Paris, France. 

1888. BERNARD ROTH, F.R.C.S. Eng., Orthopedic Surgeon 
to the Royal Alexandra Children's Hospital, Brighton. 
38 Harley Street, Cavendish Square, W., London, Eng- 
land. 

1903. W. SCHULTHESS, M.D., Privatdozent fiir Orthopadie ; 
Chefarzt am Diakonissenhause, Neumiinster. Neumiin- 
sterallee 3, Zurich V., Switzerland. 

1890. NOBLE SMITH, F.R.C.S. Edin., L.R.C.P. Lond., 
M.R.C.S. Eng., M.D., Surgeon to All Saints' Children's 
Hospital; Orthopedic Surgeon to British Home for 
Incurables; Senior Surgeon to the City Orthopedic 
Hospital. 24 Queen Anne Street, Cavendish Square, 
W., London, England. 

1899. ALFRED H. TUBBY, M.S., M.B. Lond., F.R.C.S. Eng., 
Surgeon to the Westminster, National Orthopedic, and 
Evelina Hospitals. 25 Weymouth Street, Portland 
Place, W., London, England. 

1899. OSCAR VULIPIUS, Privatdozent der Chirurgie an der 
Universitat Heidelberg, Dozent fiir orthopadische Chi- 
rurgie, dirigirender Arzt der Orthopadische Chirurgischen 
Heilanstalt in Heidelberg. Luisenstrasse No. 1. 

1890. W. J. WALSHAM, F.R.C.S. Eng., M.B. and CM. Aber- 
deen, Joint Surgeon and Lecturer on Surgery at St. 
Bartholomew's Hospital; Surgeon to Metropolitan Hos- 
pital; Consulting Surgeon to Hospital for Hip Diseases, 
Seven Oaks, and to the Bromley Cottage Hospital. 
77 Harley Street, London, England. 

1890. GEORGE ARTHUR WRIGHT, B.A., M.B., Oxon., 
F.R.C.S., Senior Assistant Surgeon, Royal Infirmary, 
Manchester; Surgeon to Children's Hospital, Pendlebury 
and Manchester. 8a St. John Street, Manchester, Eng- 
land. 





DECEASED. 




3ctt&e ffltwbztsi* 


Elected I 


1887. 


BncKMiNSTER Brown, M.D. 


1887. 


Edward Dbvblin, M.D. 


1892. 


A. E. HOADLBY, M.D. 


1887. 


Harry Hodoen, M.D. 


1887. 


Samuel Ketch, M.D. 


1887. 


George W. Ryan, M.D. 


1887. 


Lewis Hall Sayre, M.D. 


1890. 


A. M. Phelps, M.D. 




f^onntats IKembetn. 


1895. 


William Adams, F.R.C.S. 


1889. 


Henry G. Davis, M.D. 


1892. 


William Detmold, M.D. 


1889. 


WnjJAM J. Little, M.D., F.R.C.P. Lond., M.R.C.S. Eng, 


1893. 


Leopold Ollier, M.D. 


1889. 


David Prince, M.D. 


1889. 


Lewis A. Sayre, M.D. 


1891. 


C. Fayette Taylor, M.D. 




ffottt0p0ti))iitg ffUxtiittf^ 


1889. 


F. Beely, M.D. 


1894. 


Bernard E. Brodhurst, F.R.C.S. Eng. 


1892. 


Nicholas Grattan, F.R.C.S. Edin. 


1892. 


PiETRO Panzeri, M.D. 


1890. 


Hugh Owen Thomas, M.R.C.S. Eng. 



VoiiUME I. AUGUST, 1903. Numbeb 1. 

The American Journal of 
Orthopedic Surgery 



I. 

THE PRESIDENT'S ADDRESS. 



THE FAMILY PHYSICIAN, THE SPECIALIST AND 
THE PATIENT. 

LOUIS A. WEIGEL, M.D., ROCHESTER^ N.T. 

In calling the seventeenth annual meeting of the American 
Orthopedic Association to order, I must give voice to my 
appreciation of the supreme confidence manifested by confer- 
ring the highest honor within its gift upon me. To be called 
upon to preside over the deliberations of an association of 
international importance carries with it a grave responsibil- 
ity; and I trust that, when this year's work has passed into 
history, I may have honestly earned the approbation of my 
fellow-members, and that the work done by them may have 
truly fulfilled the purpose of the Association, which, our 
Constitution tells us, should be "the advancement of ortho- 
pedic science and art." To those members who so generously 
came to the assistance of the President and furnished the 
scientific material for this year's meeting I tender my especial 
thanks. 

My predecessors in office, in their annual addresses, discussed 
various phases of orthopedics, both American and foreign, its 
rank as a specialty, its past and future, its scope, its influence, 
its pathology, its institutions, its education and literature. 

PMsented at the Serenteenth Annual Meeting of the AsBociation, Washington, 
D.C., May 11-14, 1908. 



2 THE PRESIDENT'S ADDRESS. 

As the ground within the specialty has been so thoroughly 
covered, it may be well to go outside of our own compara- 
tively narrow sphere and consider briefly our relations and 
duties to the family physician and the patient. 

The good old family doctor seems almost destined to dis- 
appear completely, and unfortimately so. As a recent writer 
says:* "Families have three or four doctors,— one for the 
grown people, one for the children, and so on. If I ask you 
whether you think that the specialist can fulfil every require- 
ment that sick people need, I am sure you will agree that he 
cannot. He is good for one thing. He does not have gen- 
eral influence, nor does he have the power of mental influ- 
ence on the patient. The family doctor combines the ofl&ces 
of a father confessor and a general adviser on very many sub- 
jects. We ought to call a specialist sometimes; but we must 
have the family doctor as well, in order to understand the 
constitution or diathesis, and to develop a true roundness of 
character in treating disease." It is imdoubtedly true that 
the specialist or any number of specialists cannot take the 
place of the family adviser. It may be that the influence 
of the family physician is less potent than formerly, but this 
decline cannot be attributed to the growth of specialism. While 
this may be one of the causes, it is not the only one. In these 
days, where we have a multiplication of pathies, fads, patent 
medicines, etc., it is not strange that the practice of medicine 
has been pretty thoroughly divided up, and that patients fly 
from one thing to another and from one doctor to another 
without rhjnne or reason. Of course, present-day fads are sim- 
ply a repetition of history. The days of tar water, Perkins 
tractors, etc., are replaced by Christian Science, osteopathy, etc. 
The daily press, too, has assumed the role of teaching the 
public in matters medical, and its influence in spreading knowl- 
edge or error is certainly a very potent one. The conditions 
in the home even have undergone a great change. With the 
decadence of the family physician, the school of practical hy- 

*D. W. Cheeyer, the Quarterlv Bulletin of the Harvard Medical Alumni Aeeo- 
dationt 1903, p. 4S2. 



I 



LOUIS A. WEIGEL. 3 

giene and medicine has passed from the home circle and been 
transferred to the newspaper and magazine, — certainly a change 
of questionable character. In some communities public health 
associations are established to give reliable instruction in 
matters pertaining to health, but their influence must nec- 
essarily be limited unless supplemented by personal instruc- 
tion on the part of the family doctor, who may individualize 
and adapt conditions to surroundings. General rules cannot 
be made applicable to the individual. 

At the present day the requirements and attainments of the 
ideal family doctor are somewhat different than they were 
formerly. Even though he may not think it advisable to under- 
take the treatment of every case or every condition that comes 
under his notice, he should, at least, be competent to make 
a reliable diagnosis, but it is a matter of daily observation that 
in this respect he is somewhat at fault. We all of us know 
how frequently patients come to us with the statement that 
their family physician had been treating them for months, 
perhaps years, and during that whole time never thought it 
necessary to make a physical examination. Many anxious 
mothers are consoled with the statement that an incipient 
deformity or distortion does not amount to anything and 
that the child will outgrow it, when, as a matter of fact, the 
tendency of such deformities or distortions is to increase with 
advancing years. Palpable conditions are overlooked or 
mistaken because of the neglect to have the patient undress 
for a proper physical examination. Only recently a child 
thirteen years of age was presented who was said to have spinal 
trouble which she would outgrow in time without treatment, 
and which, upon proper investigation, proved to be a case of 
double congenital dislocation of the hips. It is not necessary 
for me to multiply instances of this kind, as you are only too 
familiar with them. When patients have taken drugs or 
other treatment for months without obtaining the relief sought 
for, it is not surprising that they finally seek the services of 
quacks and charlatans, who would not receive the same degree 
of support from the public if the family doctor were more 



4 THE PRESIDENT'S ADDRESS. 

painstaking and conscientious in examination and treatment. 
Quackery thrives largely on the shortcomings of the medical 
profession and the limitations of medicine itself. 

While we are justified in accusing the family physician of 
sins, both of commission and omission, it may be proper for 
us to make an examination of conscience and see where we 
ourselves are at fault in our relation both to him and the pa- 
tient. It cannot be denied that working along one special 
line has a tendency to narrow our point of view, and some- 
times to the detriment of the patient. The family physi- 
cian who is not thus hampered and whose field of vision is 
necessarily very much broader may frequently give us ma- 
terial help in solving some perplexing problems. A judicious 
co-operation would inure many times to the benefit of all 
parties concerned. 

A word may be said with reference to the education of the 
specialist. The specialist is not made in a day, nor can he 
be evolved from a medical college. Although there is a ten- 
dency in modem times to send full-fledged specialists into the 
world directly from college and university, — ^and a few of the 
influential medical journals advocate such a course, — I am 
etill old-fashioned enough to believe that the specialist to be 
successful requires something more than the knowledge he gains 
at school. Even granting that the science and art of medicine 
of to-day is almost too great to be mastered by a single indi- 
vidual, one cannot become a broad and liberal-minded special- 
ist before he has had the inestimable advantage of a general 
practice. A period of experience in a hospital or any other 
institution can never be considered an equivalent. At the 
bedside of the patient, in a private house, where the young 
physician is thrown upon his own responsibility, where he 
must struggle to make his own diagnosis, watch every symp- 
tom and be prepared for an emergency, he receives a training 
both of the mind and of the eye that can be acquired in no 
other way. After a period of probation and study of this 
character sufficiently long to develop the powers of percep- 
tion to the highest degree, one is better fitted to confine his 



LOUIS A. WEIGEL. 5 

efforts to some special line of work and with a greater chance 
of success. It may be said that a specialist, like a poet, is 
bom and not made. Certain qualities and aptitudes are 
innate, and are acquired with diflSculty. It is not an uncom- 
mon experience for men to have certain fixed ideas of what 
they are especially fitted for. In the course of a few years, 
however, either by force of circumstances or by certain acci- 
dents, they drift away entirely from their preconceived ideals 
and engage in activities that perhaps they never dreamed 
of. For this reason, if for no other, a general practice be- 
comes a necessity to bring out the special qualifications of a 
given person and demonstrate for what he is best fitted. As 
Dr. Cheever,* in an address, well says: "I feel that the spe- 
cialist is not so useful if he began as a specialist, and never 
did anything else, as he would be if he had begun as a gen- 
eral practitioner, and had not only learned the general round 
of professional work by study, but had also practised it. It 
used to be said that a doctor ought to have ten years of gen- 
eral practice before he became a specialist. Perhaps that is 
not strictly true as to time, but the principle is true. I have 
been struck with this over and over again quite forcibly. I 
recall cases where the specialist was of great use to me in dif- 
ferentiating the disease of a single organ; but, as time went on 
and the case developed, I could not help noticing the fact 
that he saw that organ and nothing else, and that the patient's 
general condition was not so clearly present to his mind as it 
was to mine. It seems to me that the doctor's position is 
this: that the specialist is the person who is supposed to de- 
velop an unusual amount of knowledge on a limited theme. 
If he is called in simply to give treatment or to aid diagnosis 
on that little point, perhaps that will do; but it may do harm 
if he sees that one portion and overlooks the rest. He does 
not see justly. So I am more than ever convinced of the 
fact that, although yoimg men who have settled in cities may 
be expected to have an unusual amount of knowledge and to 
be called in as experts, yet I am sure that in small conununi- 

*Loc, dt.t p. 401. 



6 THE PRESIDENT'S ADDRESS. 

ties the general practitioner is and always will remain the 
doctor." 

It is incumbent upon this Association to promote a devel- 
opment and improvement of orthopedics by insisting upon 
the proper qualifications of men who are to take up this spe- 
cialty. We should take special care in selecting candidates 
for membership, so that only those who show the greatest 
amount of special aptitude, in addition to a general knowledge 
of medicine, shall become associated with us. If we require 
of the family doctor that he be sufficiently well versed in all 
branches of medicine to make a diagnosis at least, we, on the 
other hand, should also be sufficiently well educated in gen- 
eral medicine to give proper weight to all conditions that 
may modify the treatment of a special case. This is surely 
not too much to expect of us. Perhaps the specialist of to-day 
may be defined as one who has given special attention and 
study to one branch of medicine in addition to a general knowl- 
edge of all other branches, such knowledge to be based on prac- 
tical experience at the bedside in the home for a sufficient 
length of time to broaden the mind and to train his powers 
of observation and self-reliance. There are many things to 
be learned outside of the laboratory. 

In my triumvirate I have placed the specialist in the mid- 
dle, because he should form the connecting link in the chain 
of mutual confidence between the family physician and the 
patient, and also because he must sometimes act as a buffer 
to lessen the shock of a possible collision between them. There 
need not necessarily be any conflict between the family doctor 
and the specialist, and there would be a better feeling of fel- 
lowship between them if they co-operated more frequently 
in the treatment of a patient. I am afraid that we do not 
always follow up our patients sufficiently well to know the 
final result of our treatment. This is especially true of opera- 
tive work. If we paid more attention to the subsequent his- 
tory of the patient than to the immediate success of an opera- 
tion, I am inclined to believe that we would many times change 
our views and modify our methods of treatment. The family 



LOUIS A. WEIGEL. 7 

physician, who is able to keep a patient under observation 
for a long time, is best fitted to aid us in this direction. 

Medicine is classed as a liberal profession, but, unfortunately, 
many of its members are illiberal and bigoted. At times there 
is a lamentable absence of the esprit du corps. Narrow- 
mindedness and bigotry are responsible for many petty jeal- 
ousies that do not benefit the patient, the one most vitally 
interested in the success of medical practice. Active co- 
operation, mutual confidence, and the practice of the Golden 
Rule certainly should mark the relation between the family 
doctor and the specialist. The charge has been made that 
loyalty to the family physician has been impaired by special- 
ism, and given rise to hesitation and distrust of the family 
doctor. I am not inclined to agree with this sentiment, for 
I believe there are other and more potent causes to account 
for the apparent decadence of the family doctor. 

The human mind is so constituted that it is always striving 
after the marvellous, the wonderful, and the unusual, while 
the conmionplaces of every-day life attract no attention what- 
ever. This was illustrated in the recent visit to this country 
of one of our corresponding members, which gave occa- 
sion to a newspaper discussion of orthopedics. You all know 
how assiduously and eagerly the public devoured the sensa- 
tional stories, and accepted every statement as gospel truth, 
no matter how improbable or exaggerated it may have been. 
I simply refer to this to show how much the public is inter- 
ested in medical matters, and how easily it is swayed in one 
direction or another. There is no question that our specialty 
has derived a direct benefit from the newspaper discussion, but 
it remains for us to educate the public as to what may be done 
and what may be impossible in orthopedic surgery. We 
may not be able to impress some people by our prosaic methods, 
but this should not deter us from dealing honestly and con- 
scientiously with all who come under our care. In giving 
our best thought and attention to the patient, and seeking 
the co-operation of the family physician in all important mat- 
ters, we will in return secure a degree of confidence that could 



8 THE PRESIDENT'S ADDRESS. 

not otherwise be attained; and, even though our best efforts 
may not always be appreciated at their true worth, we can, 
at leacit, have the consciousness of having done our duty. 

Since our last meeting we have suffered the loss of an active 
member and a former president of the society. It is not nec- 
essary for me to write an elaborate eulogy of Dr. Abel Mix 
Phelps, because his work, his originality, and his contributions 
to scientific surgery are an enduring monument. The mem- 
bers of the Association who came in intimate contact with 
him fully appreciated his force of character. Although im- 
petuous in the extreme, there was an element of kindness in 
his nature that was not generally known. There were many 
sides of his character that are worthy of emulation. 



II. 

THE CORRECTION OF DEFORMITY AT THE HIP, 
THE RESULT OF DISEASE: A STUDY OF THE 
BEST METHODS AND BEST POSITIONS. 

VIRGIL P. GIBNEY, M.D., NEW YORK. 

When Mr. Gant, the English surgeon, advocated subtro- 
chanteric osteotomy for the correction of deformity resulting 
from hip disease, this operation was regarded as a distinct 
improvement over that advocated by the late Mr. Adams; 
namely, osteotomy through the femoral neck. For some 
years orthopedic surgeons have been operating after Gant's 
method, and papers with elaborately compiled statistics have 
been presented from time to time to the American Orthopedic 
Association. While some of our fellows have not been fully 
satisfied with the results of the operation, I think that it might 
be safe to say that the majority have looked upon this simple 
subcutaneous osteotomy about the level of the trochanter 
minor as the safest procedure extant for the correction of 
deformity at the hip. It is certainly within the experience of 
the writer of this paper to have encoimtered disastrous results 
from either the subcutaneous or the open operations through 
the joint; and, while a faulty technique may be the cause of 
some of the results, he, at least, prefers the Gant operation. 

During the month of December, 1902, Professor Lorenz, 
in a paper read before the Orthopedic Section of the Academy 
of Medicine, advocated the "centric" correction of deformi- 
ties of the hip, and he was so positive in his assertion that this 
was far preferable to the "excentric" that it has occurred to 
the writer that a discussion would not be inopportune or out 
of order. Hence this paper. 

It is not intended to present an array of statistics, but to 
discuss the question from a clinical standpoint. 

FKoented at the Seventeenth Annual Meeting of the Association, Washington* 
D.G.. May 11-14, 1908. 



10 DEFORMITY AT THE HIP. 

Case 1. — ^A girl, L. G., nine years of age, was admitted to 
the Hospital for Ruptured and Crippled on February 24 of 
the present year. She had been under treatment in the Oat- 
patient Department for a long time, and had previously been 
under treatment in the Post-graduate Hospital. Suffice it 
to say that a year before her admission to our hospital the 
disease was regarded as fully arrested, and the little deformity 
was considered as of no consequence. Shortly before her 
admission she began to walk poorly, and we found the hip 
pretty well locked, and that movements excited a little spasm. 
It was thought, however, that the ankylosis was fibrous; 
and, in view of the absence of any sjnnptoms about the hip, 
she was on March 3 anaesthetized and subjected to forcible 
correction of the deformity by manual force. The joint was 
not moved, as in brisement forck, but the pelvis was steadied 
and the limb pulled down into a good position, and the usual 
plaster of Paris bandage was applied for maintaining the cor- 
rection. She rested poorly that night, and we were obliged 
to keep her in bed for about four weeks on account of a daily 
temperature and pain on handling. The plaster was removed 
on April 2, and the parts were found to be quite sensitive, 
yet there were no signs of abscess. She had lost flesh. Trac- 
tion was employed temporarily, but on the 6th there was 
just enough tension above the trochanter major to suggest 
an aspiration, which was made with the large needle with 
negative residts. The high temperature continued, ranging 
from 99° F. to KH"^ F. until the 20th, during which interval 
she had a good many night cries. Under an anaesthetic, on 
this date, an incision was made into the joint just above the 
trochanter, when some thickened pus and diseased bone were 
removed with a curette. The joint was pretty thoroughly 
emptied, and the wound closed with catgut without drain, 
and plaster of Paris was applied. Her improvement dated 
from that operation. She has not had any night cries since, 
the temperature has fallen to normal, and on April 30 the 
report is that her condition is all that can be desired. 

Now this case is at least suggestive of damage done to tissues 
undergoing repair and the lighting up of the old inflammatory 
process, and it would seem that the operation for the relief of 
the joint tension was opportune. Taking into account the 
extremely sensitive condition induced by the forcible correo- 



VIRGIL P. GIBNEY. 11 

tion and the persistence of the temperatiire^ it is fair to assume 
that an abscess with extensive suppuration would have re- 
sulted; and all this is traceable to the bloodless operation re- 
sorted to at the time of her admission. 

On the other hand, there are cases innumerable where the 
same amoimt of force has been employed, the same correction 
secured, without any untoward ssonptoms. But the case I 
have cited is not a solitary one, and at the hospital we have 
long since learned that it is unsafe to resort to forcible correc- 
tion where sinuses lead to the joint, no matter how long-stand- 
ing these may be. Indeed, we hesitate to do a subtrochanteric 
osteotomy for fear that the osteotome may invade a focus of 
disease more or less active. 

One is ready to admit that a longer limb can be secured by 
the "centric" correction, but one must also admit that it is 
exceedingly difficult to determine when a joint is ready for the 
employment of force enough to correct fully. Even if the 
forcible correction at the joint is always devoid of risk, the 
pathological dislocation and the destruction of the head and 
neck preclude the possibility of a limb as long as its fellow, 
and it may be asserted that the little difference in favor of 
a lengthened limb is hardly a good enough reason to make this 
an operation preferable to the osteotomy below the joint. 
Certain it is that many of the most satisfactory results, so 
far as improving the length of the limb is concerned, have 
been accomplished by subtrochanteric osteotomy. It is the 
experience of many who have collected statistics from the Hos- 
pital for Ruptured and Crippled to find a certain number of 
relapses after subtrochanteric osteotomy. It is also the experi- 
ence of these gentlemen that relapses occur just about as fre- 
quently after forcible correction through the joint. It may 
be that our retention apparatus has not been sufficiently long 
employed, and the results obtained by Professor Lorenz may 
be due to prolonged use of plaster of Paris after the operation. 
It has long since been our conviction at the hospital that 
the plaster of Paris was not used long enough, and within the 
past two or three years it has been our custom to maintain 



12 DEFORMITY AT THE HIP. 

this correction over long periods of time, say from three to 
six months. 

The following case is one where relapses have occmred 
after osteotomies below the trochanter: — 

Case 2. — A boy, now fifteen years of age, was admitted to 
the hospital in October, 1897, for the correction of deformity 
after hip disease. A day or two later the deformity was cor- 
rected by division of the adductors and the tensor vaginae 
femoris and forcible correction. Plaster of Paris was employed, 
and on October 26 it was found, on removing the plaster, that 
the deformity was not fully corrected, so another attempt 
was made under an anaesthetic. On November 10, same year, 
the deformity had recurred in spite of the plaster of Paris; 
and the hip was stretched under ether, so that 180® was meas- 
ured before the plaster was applied. On November 20, on 
removing the plaster, the best that could be had was 165®. 
In January, 1898, the deformity had increased while wearing 
a hip splint with thoracic attachment, and the best that could 
be had was 145®. So on the 12th an osteotomy through the 
trochanter minor, subcutaneously, was performed, the deform- 
ity being fully corrected. Plaster of Paris was employed, 
and on the following day he developed measles, and was taken 
to the Reception Hospital. On his return, at the end of a 
week or ten days, it was noted that the deformity was still 
155® in extension. On August 4, 1898, his angle of deformity 
was still 155®, and he had suffered no inconvenience from any 
of the stretchings or operations. On January 7, 1899, an 
attempt was made to correct the deformity without an oste- 
otomy, an angle of 175® being obtained. The plaster was re- 
moved on January 28, and a brace applied, 165® being the 
record at this time. He went into the country, and on May 
3 he returned with two discharging sinuses, these having oc- 
curred in old cicatrices. At this time his angle of deformity 
was 160®. By July 26, 1899, it had reached 150®. He was 
discharged finally from the hospital on November 15, 1899, 
the sinuses having closed, and he was walking very well on a 
high shoe, but the limb was in deformity. He was readmitted 
May 31, 1901, his angle of deformity being 150® again. There 
was marked lordosis, and the trochanter was above N<51aton's 
line. On June 4 he had another osteotomy, Gant's, and he 
was kept in plaster imtil July 15. On July 20 measurements 
showed that his limb was down to 180®. The plaster was 



VIRGIL P. GIBNEY. 13 

not continued, but he wore a brace, and on November 20 
the best that could be obtamed was 145°. There had been 
no acute symptoms of any kmd, and he was walking without 
apparatus. On November 26 the limb was stretched again 
. imder ether and the adductors divided subcutaneously, and 
on May 10, 1902, his angle was 150°. He was discharged from 
the hospital again, and on April 14, 1903, he was readmitted, 
and in a few days thereafter, the deformity being quite as 
marked as ever, a cxmeiform osteotomy was done through the 
trochanter and what remained of the head and neck. The 
base of the wedge was IJ inch, and, when the limb was brought 
quite straight, the cut surfaces of bone came in apposition. 
This patient, it will be seen, had about five or six stretchings 
under ether, two Gant's osteotomies, and one cimeiform oste- 
otomy, the last; and it is proposed to keep him in plaster for 
several months. 



It has been suggested that, if disease does occur after forci- 
ble correction, the symptoms are of slight import, and that 
fixation in a well-fitting plaster of Paris bandage is sufficient 
to guard against any serious relapse. The case already re- 
ported in this paper is one that fails to substantiate this argu- 
ment. Again, a great many surgeons believe that tuberculous 
meningitis is directly induced by the forcible breaking-up of 
an old tuberculous focus about which repair has already been 
established, and statistics are inadequate to convince surgeons 
that such is not the case. Our own studies at the hospital, 
based upon numerous tables of statistics, have failed to show 
that there is any direct relationship between forcible correc- 
tion and tuberculous meningitis. The cases that are some- 
times adduced as evidence are those in which the second stage 
of tuberculous meningitis has developed too soon after the 
operation, or where the first stage has developed too long after 
the operation. Still, a certain amount of respect must be 
paid to the old adage, " It is a risky thing to disturb a sleeping 
dog." 

The subcutaneous operation so favored by orthopedic sur- 
geons has been so bitterly assailed by general surgeons that 
it may be well for us to discuss the relative merits of the open 



14 DEFORMITY AT THE HIP. 

and the subcutaneous operations. So simple an operation as 
subcutaneous achillotomy, done for so many years by ortho- 
pedic surgeons the worid over, has been condemned by the 
general surgeon because, forsooth, a small vessel has been 
occasionally injured, and timid operators in this specialty 
have gone so far as to admit that the tendo Achillis should 
be divided by the open method. If the impetus given to 
bloodless surgery is to be productive of any good results, let 
us continue to resort to the subcutaneous division of tendons. 
There are a few orthopedic surgeons who claim that the teno- 
tome is a valuable adjunct to our armamentarium. 

If one does an osteotomy, it should, in the judgment of the 
writer, be a subcutaneous one, because the osteotome is just 
as tractable in the hands of a skilful operator as the tenotome. 
It serves as a probe or guide often, and one can tell whether 
he is in compact bony tissue or in spongy tissue. The instru- 
ment can be so directed as to avoid wounding anything more 
than the periosteum, and the little hemorrhage that takes 
place is of no account whatever. 

The conviction has grown upon me that the position must 
be maintained for many months in a closely fitting plaster of 
Paris bandage. It is in evidence that recurrences have been 
due to short periods in plaster of Paris. When it is necessary 
to remove the plaster, then apply a closely fitting splint, like 
the Thomas, for several months afterwards. In some instances, 
an aluminum corset with a steel spring extending over the 
hip previously deformed, down the thigh acting as a lever, 
should take the place of the Thomas splint, but the principle 
is the same. 

The question is often raised whether to have an ankylosed 
limb perfectly straight or slightly flexed. From my own ex- 
perience in the management of these deformities I am con- 
vinced that the limb should be left as nearly straight as is pos- 
sible. A certain amount of flexion will take place, but, if very 
slight, the patient certainly walks a great deal better and is 
in less danger of developing a painful hip in after years. Many 
cases of neuralgia of the limb or pain on walking have come 



DISCUSSION. 15 

under my observation, and I have been able to relieve 
them by correcting the deformity. There are, undoubtedly, 
many patients who prefer a slight flexion, so that they may 
sit more comfortably, but these belong to the younger class. 
It is the opinion, therefore, of the writer of this paper that 
ability to sit comfortably should be sacrificed to the abihty 
to stand and walk erect. 

DISCUSSION. 

Dr. A. J. Steele reported the case of a boy of eight years who had 
heen in the hospital for several months with extreme flexion of both 
hips from old hip disease. The speaker said he had been making gentle 
traction, hoping to get the hips down. Dr. Lorenz called special atten- 
tion to this case, and insisted that it was an admirable one for carrying 
out Lorenz^s theoiy. In accordance with this advice the resisting tis- 
sues were divided and the necessary force used. The immediate result 
was veiy gratifying ; but a few weeks later fever and pain indicated 
that the old tubercular disease had been rekindled, and in a few weeks 
more the boy died of tubercular meningitis. He thought, therefore, 
that one should make haste slowly in these old tubercular joint troubles. 
His own experience was that there was danger of tubercular meningitis 
if extreme force were used in these cases. 

Dr. BmLOK placed on record five cases which he had operated upon 
immediately after Professor Lorenz's visit to Chicago. There were five 
hips in three patients. In four of these hips, after cutting subcutane- 
ously the adductors and long flexors, he was able by very great force to 
correct the deformity of flexion and adduction, and obtained as good a 
position as desired. In the other hip he used as great force as he 
dared, after having cut the flexors and adductors, but could not correct 
the deformity. All of the cases had no motion when the operation was 
attempted. All were old cases, and all had flexion deformity of about 
a right angle with some adduction. In the fifth case Lorenz's recom- 
mendation of driving the osteotome as close to the acetabulum as pos- 
sible was followed. The bone was divided as freely as seemed necessary ; 
and then with considerable force the remainder of the bone was broken, 
and the adductors and flexors were cut freely and the deformity cor- 
rected. All of the cases had lived, and the plaster had been removed 
from all. In all the deformity had remained corrected ; and, to his 
amazement, in all there were from five to ten degrees of motion. 

Dr. GoLDTHWAiT placed on record a series of sixteen cases operated 
upon during the past winter at the clinic, mostly in adults, because it had 



16 DEFORMITY AT THE HIP. 

been found that the relapses in adult life or after the age of seyenteen 
were very much less frequent than in childhood. It had been their 
custom to keep the patients in a protection apparatus until this age was 
reached, and then operate. Among the adults there had been no re- 
lapses. Some of the pictures from these cases were exhibited. 

Dr. Shaffer referred to several cases in which forcible means were 
used to correct the deformity of old hip disease. One of the cases was 
regarded by the hospital suigeons as one of dislocation, the deformity 
being so extreme. The patient was not suffering much pain at the 
time. He was etherized, and the deformity corrected ; and it was dem- 
onstrated that there was no dislocation present He had no doubt that 
as a result of the manipulation an abscess was now forming. Another 
<sase was one in which under ether the deformity was reduced very much 
AS described by Dr. Bidlon. Thus far the results were negative. There 
were no particular symptoms. While he was open to conviction regard- 
ing the propriety of performing this operation in advanced cases, he was 
yet to be converted, because he had seen so many disastrous results 
follow forcible measures used simply for the correction of deformity in 
old cases of hip-joint disease. 

Dr. Joseph Kubtz, of Los Angeles (by invitation), spoke of the 
question of the open or the subcutaneous method of osteotomy. Per- 
sonally, he had long practised the open method of osteotomy because 
it was quicker and safer. Dr. Gibney had made the statement that 
some surgeons were afraid of injuring certain important structures ; but 
there was no occasion for this, and with modem aseptic methods there 
was no reason to fear infection. A large incision was not demanded. 
The periosteum should be cut down upon, and then peeled off. With 
the osteotome it was very easy to divide the bone to the desired extent. 
There was a chisel made which was guarded by a projecting edge. 
This was pushed in under the periosteum. With two or three strokes 
one could readUy break through the bone more quickly than by the 
subcutaneous method, and it was much safer. 

Dr. Gibney said he was glad that Dr. Goldthwait had brought up 
the question of relapses in adults. It accorded with his own experi- 
«nce that relapses seldom occurred in adults. The last speaker said 
there was no reason to fear infection. He sincerely wished this was 
strictly true, but his own opinion was that even the surgeon most 
skilled in aseptic technique did sometimes get infection. The plea had 
been made for the open method because of the shorter time, — an argu- 
ment which did not appeal to him. Yesterday he had done two suprar 
condyloid osteotomies for knock-knee and two osteotomies for antero- 
posterior curvature of the tibia, and the whole time consumed from the 
41me of beginning the ether to the close was about thirty-five minutes. 



III. 

SUBTROCHANTERIC OSTEOTOMY IN ADULTS, IN 
ADOLESCENTS, AND IN YOUNG CHILDREN. 

E. H. BRADFORD, M.D., BOSTON. 

The fracture of so important a bone as the femur within 
a short distance of the pelvis in adults is a procedure not to 
be hastily undertaken. Non-union or delayed union is a pos- 
sible consequence which would be deplorable. It is for this 
reason that a careful study of cases operated upon by this 
method is of value. From theoretical reasoning it would ap- 
pear that the danger of non-union might be great from the fact 
that the operation is undertaken for deformity, and in the 
correction of deformity it is necessary to arrange for a union 
which would place the fragments of the bone at an angle. 
The distorted limb is usually flexed and abducted. In order 
that the resulting limb should be well under the patient, it is 
necessary that the lower fragment should be in the longitudi- 
nal axis of the body, leaving the upper fragment in its former 
distorted position. This causes considerable angle of the 
fragments. A imion, therefore, must take place in a distorted 
position, and the first fear of a surgeon in undertaking the 
operation would be the possibility of non-union or of delayed 
union of bones in any except actively growing children. 

From the following cases it would appear that this danger 
of non-imion is not great. It is possible that the danger of 
non-union or of delayed imion is less in artificial fractiu'e by 
the use of the osteotome than after accident, from the fact 
that, if the operation is carefully done, the periosteiun is not 
injured. There is also little probability of the interposition 
of muscular or fibrous tissues between the fragments. It is 
certain that in the cases which have come under my care there 
appeared to be no grounds for apprehension of non-union. 

Fl««ented at the Seyenteenth Annnal Meeting of the Aflsociation, Washinfirtoxi, 
D.C., May 11-14, 1903. 



18 SUBTROCHANTERIC OSTEOTOMY. 

Case 1. — "P." A lady of forty-five years of age, of good 
health, with ankylosis at the hip joint, with a flexion of 80^ 
and an abduction of 30^, dating from hip disease in early child- 
hood. The patient was obliged by her occupation to stand 
constantly, which caused considerable pain about the hip, 
back, and thigh. This pain was most severe at the end of 
the day's work, and interfered seriously with the discharge 
of her duties, which demanded considerable activity. After 
careful consideration of the danger from the operation, sub- 
trochanteric osteotomy was decided upon and performed. 
The operation was done in the usual way. The division of 
the bone was slightly oblique. No traction force was used, 
but the limb was placed in plaster with the flexion entirely 
corrected. The limb was abducted to 45®. Plaster of Paris 
was applied, and the patient placed in bed, secured by a bed 
frame. No reaction followed the operation, and her recovery 
began without interruption for two weeks. At this time a 
digestive disturbance was occasioned by extreme hot weather 
and slight error in diet. The patient was somewhat weakened 
by this, and nervous prostration followed, partly due to the 
reaction of the operation, partly to the confinement in bed of 
an active woman, and partly to the reaction which followed 
the over-activity and overwork previous to the operation. 
This condition lasted for the following three months. The 
union of the osteotomized femur, however, was firm at the 
end of two months, and the plaster was removed, but the 
patient was unable to walk about until three months later, 
and it was six months from the operation before the patient 
was able to resume her occupation. There has been no re- 
lapse, and a shrinking from the portion of abduction only 
to about 10*^, making the length of the limbs equal where pre- 
viously there had been an actual shortening of an inch and a 
half, and a practical shortening, owing to the deformity and 
tilting of the pelvis, of four inches. The recovery has remained 
permanent without relapse for three years. 

Case 2. — "S." Aged forty years, a school-teacher, stout 
and nervous person, with a deformity at the hip, with, how- 
ever, a few degrees of motion at the hip joint. The limb was 
held in a position of flexion and abduction, with a practical 
shortening of three inches. Osteotomy was performed as 
in the previous case, with a more rapid and immediate recov- 
ery. The patient was able to return to her home from the 
hospital after two months. The plaster was removed, and 



B. H, BRADFORD. 



19 



the union seemed finn. Some nervous disturbance followed. 
Was unable to walk imtil nearly six months after the opera- 
tion. She took up her occupation as school-teacher a year 
after the operation. The recovery has been complete, and 
the patient is now able to walk without difficulty. 

Case 3. — "C." Patient twenty-five years of age. Hip 
disease with ankylosis and moderate deformity, with a prac- 
tical shortening of three inches. Osteotomy was done in the 
ordinary way, and the patient made a good recovery in two 



) 




Tracing from a akiagram one year after sabtrochanteric oeteotomy, Bhowing angle 
in the ahaft of femnr after oocreotion of deformity. 



months, and was able to walk without crutches in three months 
from the operation. The patient was light and active. No 
relapse occurred. A shrinking in a position of forced abduc- 
tion from 45** to 20** followed, but enough was left to main- 
tain the equality of the limb. 

Case 4. — "G." An active young gentleman, twenty-one 
years of age. Had grown rapidly, and was tall and slight, 
with a bad right-angled contraction and 10** of abduction at 
the right hip. Osteotomy was done, the limb being placed 
in a position of forced abduction. The case, however, was 
allowed to move about at the end of two months, and a loss 
of abduction resulted, so that the legs became parallel. Six 
months later a second operation was done, and a position of 



20 SUBTROCHANTERIC OSTEOTOMY. 

abduction again secured. This position remained, the patient 
being kept in bed for three months. The deformity was com- 
plicated, however, by a condition of knock-knee, which was 
foimd to have existed, making locomotion difficult, and an 
osteotomy at the lower end of the femur (McEwen's opera- 
tion) correcting the knock was performed. This made the 
walking almost normal, and locomotion remained without 
noticeable limb and deformity. The cure has remained 
perfect for five years without relapse. 

Case 5. — "R." A girl of eighteen, slight of figure. Suf- 
fered from hip disease in early childhood with the character- 
istic deformity, including marked shortening. Osteotomy 
was performed in the usual way, and a position of forced ab- 
duction maintained. The patient was kept in bed for nine 
weeks, wearing a retentive leather apparatus for six months, 
locomotion with crutches being permitted. No relapse has 
followed. The shortening has been entirely overcome. 



It would appear, therefore, that non-union or delayed union 
is not to be considered in estimating the advantages to fol- 
low the operation. 

The danger of recurrence of the deformity is also a factor 
of importance in judging of the ultimate value of the proced- 
ure. Where marked deformity exists following hip disease, 
to an extent to justify subtrochanteric osteotomy for the 
correction of the deformity, the conditions are usually of 
firm ankylosis at the hip joint, with a faulty position of the 
limb. The femur is strongly abducted and strongly flexed. 
Tliere is a certain amount of actual shortening from the sub- 
luxation of the femur, from the absorption of the head and 
the enlargement of the acetabulum, and there is considerable 
degree of practical shortening. The fimctional benefit which 
is obtained from the operation consists not only in correcting 
the abduction, but in causing a union in a strongly abducted 
position, the amoimt of abduction being proportionate to the 
amount of practical shortening; for it will be readily seen 
that, if the limb which was abducted at 45^ from the longi- 
tudinal axis of the body be abducted to a corresponding extent, 
the pelvis, which was tilted in such a way that the affected 



E. H. BRADFORD. 21 

side is raised, will, when the abduction becomes fixed by anky- 
losis, become tilted in exactly the opposite direction, and the 
well ade will become the elevated one, and the lower side the 
one previously raised. 

By this means it will be found that a shortening to the ex- 
tent of three or even four inches can be overcome. It is evi- 
dently necessary that the union under these circimistances 
should be firm. Unless the pelvis adapts itself by the approach 
of the normal leg to the corrected position, the patient cannot 
walk. Either the well limb must be brought to the new posi- 
tion, or the limb operated upon will return to its former dis- 
tortion. There is, therefore, a constant tendency for the limb 
to fall back into its former position, not so much from muscu- 
lar action of the adductor muscles as from the constant pull 
of the weight of the leg, and the constant tendency on the 
part of the patient to bring the leg toward the median line. 
It would appear that this tendency to relapse is greater in 
children than in adults, probably for the reason that in grow- 
ing bone the ossification and union of fractures is less of a 
bony character, or that the ligamentous union remains longer 
in adults where either non-union exists or strong imion. This 
would appear to be the case from the comparative results in 
the following three cases: — 

Case 6. — "S." A rapidly growing boy of thirteen was 
operated upon for bad deformity at the hip, following severe 
hip disease. The usual correction followed with no apparent 
relapse for a year following the operation. The boy then 
grew rapidly, and a recurrence of the deformity took place, so 
that at the age of eighteen there was a shortening of four inches, 
partly due to the abduction and partly due to the greater 
growth of the other limb. The patient died six years later 
of phthisis. At the time of death the limbs were parallel, 
and there was but Uttle flexion and no abduction, but the 
position of forced abduction and gain in length of the limb 
had been lost. 

Cases 7 and 8.— " A " and "B." Boys of twelve and thir- 
teen years of age respectively, both rapidly growing, and the 
operation being the same as in Case 7. Loss of forced abduc- 



22 SUBTROCHANTERIC OSTEOTOMY. 

tion in both instances; the limb remaining in a position parallel 
to the long axis of the body^ but with a loss of the position of 
forced abduction. 



If these conclusions are correct, it would appear that it is 
necessary for children to wear retentive apparatus or to be 
kept in a recumbent position relatively longer than would usu- 
ally be the case after fractiu^. It is necessary that retentive 
apparatus in children should be worn longer than in adults, 
partly also from the active natiu^ of children, who, as soon 
as discomfort is relieved and any pain on motion ceases, are 
apt to throw weight on the limb without careful considera- 
tion of the way in which the weight falls. Furthermore, as 
the weight of children is less than that in adults, the child at- 
tempts to use the limb more quickly than could be done in 
adults, and for this reason less care is exercised in guarding the 
limb in the corrected position. It would appear that not 
only should no child be allowed to walk upon the limb until 
eight weeks has elapsed after the operation, and a subsequent 
period of eight weeks should be insisted on for semi-recumbent 
treatment, in order to prevent the possibility of relapse of 
the deformity; and in rapidly growing children a longer time 
is needed. 

Another factor to be considered is the tendency in growing 
bone to reproduce by growth the position of the deformity. 
This would be apparently the case in all rapidly growing chil- 
dren that have come xmder my care, and it is for this reason 
that the operation does not seem to adapt itself to that of 
the very rapidly growing period. Where the operation is 
undertaken in younger children, a long after treatment should 
be insisted on. This is also true, to a degree, in early adoles- 
cents ; but, as the growth of the bone is nearly accomplished, 
the factor to be considered is the care of after-treatment 
until the bone is imited rather than the subsequent growth 
of the bone. 

In brief, it may be said that the operation of subtrochan- 
teric osteotomy for the correction of the deformity following 



E. H. BRADFORD. 28 

hip disease is one which can be done in adults without fear 
of non-union, or even in middle life, and that the danger of re- 
lapse is greater when the operation is done in childhood or in 
rapidly growing years. The danger of non-union is appar- 
ently not an imminent one when the operation is done in 
adults, but the period of convalescence and disability after 
the operation is comparatively long when the operation is 
undertaken in middle life. For this reason it would seem 
to be better surgery to defer the operation, when possible, 
in young childhood until the period of rapid growth has been 



IV. 

THE MECHANICAL v. THE OPERATIVE TREATMENT 
OF RACHITIC DEFORMITIES OF THE LOWER 
EXTREMITIES, PRESENTING A NEW OSTEO- 
CLAST. 

R. TUNBTALL TAYLOR, M.D., BALTIMORE. 

What I have to say is very brief in this connection, and is 
in behalf of the immediate correction of rachitic deformi- 
ties of the lower extremities by either manual or mechanical 
straightening in the stage of softening, or osteoclasis or osteot- 
omy in the stage of ebumation. 

In 109 consecutive cases at the Hospital for Crippled and 
Deformed Children, the following deformities (genu valgum 
42, genu varum 59, and anterior bowing of the tibia 8) we have 
operated with only two relapses and one over-correction (a 
genu valgum complicating a genu varum, requiring a secondary 
operation to obtain a satisfactory result). 

We have not discriminated, as is usually done, and put 
braces on the very young with flexible bones, but simply under 
ether straightened these legs manually or instrumentally, 
used fixation in plaster in slight over-correction for four to 
six weeks, and instituted proper feeding, good hygiene, and 
fixation on a Bradford frame, until all symptoms of the so- 
called "acute rickets" are passed, as shown by absence of ihe 
usual manifestations and presence of improved nutrition. 

In only two cases, so far as I can find in our records, have 
braces been employed, and these were not satisfactory in the 
results obtained. 

My reasons for holding these views are: — 

First. When we take into consideration the primary cost 
of braces to this class of cases, which we find among the negroes, 

Presented at the Seventeenth Annual Meeting of the Association, Washington. 
D.C., May 11-14, 1803. 



R. TUNSTALL TAYLOR. 25 

Italians, and poorer claases of Americans in our dispensaries, 
we must needs feel that any immediate correction of the de- 
formity which will obviate the expense of braces is desirable. 

Second. The objection raised by one of my New York 
friends, that they ''could not habitually operate on bow-legs 
and knock-knees there, because the parents would not con- 
sent, and 'had seen other children with suitable braces for 
the deformity,'" we meet, not by suggesting "an operaHon 
to break the legs," but by "a suggestion that we give the 
child a little gas and bend the logs straight," which we do often 
then and there. Seldom are we refused, especially when we 
tell them that the child's legs will have to be held straight 
in plaster of Paris for four to six weeks, and will require noth- 
ing to keep the deformity from returning. 

Third. The danger of these operations needs not deter us 
in the slightest d^ree with modem asepsis (I speak of oste- 
otomy) from resorting to the operative method. Osteoclasis 
for genu varum is one of our simplest and most harmless pro- 
cedures, even standing ahead of tenotomy of the tendo Achil- 
lis in its simplicity. 

We have not infrequently sent home the same day that 
the operation was done in the dispensary, not only the cases 
of genu varum after osteoclasis, but genu valgum also. 

With plenty of padding under the cast, especially at the 
seat of the fracture and between the toes, these patients have 
little or no discomfort except from the restraint offered by 
the plaster, and are cured by the time the braces, had they 
been ordered, would have come from the instrument-maker 
and been property adjusted to be worn in the daytime. 

I say "daytime," for, with the usual forms of braces for the 
rachitic deformities of the lower extremities, we have the 
shoes as the lower attachment, and hence we have them taken 
off for ten hours at night and for two hours at mid-day for the 
nap then. Twelve hours with and twelve hours without 
braces in the twenty-four! 

Fourth. The comparison of the length of time the child 
has to submit to the discomfort of the plaster bandages versus 
the braces is wholly in favor of the operative method. 



26 TREATMENT OF RACHITIC DEFORMITIES. 

In conclusion, I wish to present to the Association a new 
osteoclast, which I have devised on the lever principle instead 
of the screw, as seen in Rizzoli's, Grattan's, Colin's, and Lo- 
renz's osteoclasts. 

It consists of a T-shaped base, the arms of the T being some 
twelve inches wide and the stem some thirty-six inches long. 
Arising from the intersection of the arms and on the stem is 
an arc some twelve inches high at its smnmit and twelve inches 
wide at its base. 

Some three inches above and parallel with the stem of the 
base is a movable half-inch square rod which may slide back- 
ward and forward through slots in the arc. 

From the summit of the arc depends the short arm of the 
lever some jiine inches down to its attachment to the movable 
rod. The long arm of the lever extends backward at a right 
angle to the short arm some twenty-fom* inches. It is fastened 
at the top of the arch by a bolt allowing free play. 

Its attachment to the movable rod is by means of a notch 
to receive the rod, an inch by one-fourth of an inch slot on 
the sides, through which may pass and play a pin into one of a 
series of holes which can be used to regulate the length of the 
movable rod beyond the top of the T where it has attached, 
by a swivel joint, a pressure plate. 

Two C-shaped arcs of the usual t3rpe are attached and reg- 
ulated by set screws on the arms of the T for children for differ- 
ent length legs. 

For adjustment to legs of varying circumferences the pin 
through the slot can be adjusted, so that, when the lever is 
pressed down after the leg has been placed against the C- 
pieces, the forward thrust of the movable rod may be extreme. 
For genu valgmn both C-pieces may be put on one side. 

The advantages claimed for this device are the rapidity of 
the fracture and release, which cannot be obtained with the 
other osteoclasts. It can be taken apart readily for carrying. 



V. 

THE SURGICAL PATHOLOGY OF GENU VARUM AND 
GENU VALGUM, 

WALLACE BLANCHARD, M.D., CHICAGO. 

All surgical proceedings should be governed and bounded 
by the indications and limitations of existing pathological 
knowledge. I do not know that I can add anything to the 
present accepted pathology of genu varum and genu valgum, 
but I may be able to demonstrate that there is occasionally 
a wide divergence between the well-known pathological in- 
dications, on the one hand, and the surgical procedures, on the 
other. Although genu varum and genu valgum are usually 
rachitic deformities, yet it is well understood that a very con- 
siderable proportion of these deformities of the legs occur 
in children in whom no symptoms of rickets are observed. 

Ebumation may be premature or dilatory without any 
actual disease, just as dentition or adolescence may be early 
or late without pathological significance. The healthy, well- 
nourished child may walk early and have bones that harden 
slowly, and a deformity of the legs that is only apparently 
rachitic may develop. 

The skiagraphic observation of a large number of cases of 
genu varum and genu valgum would seem to prove quite 
conclusively that these deformities very largely follow fixed 
laws of development. 

Different healthy individuals show the normal curves in the 
long bones to a more or less pronoimced degree, and it has 
been observed that the greater variational tendency lies in 
the natural curves to exaggerate and become deformities. 

Advanced genu varum generally shows three contributing 
curves, the primary deviation being usually an exaggeration 

Ptmented at the Serenteeiith Annual Heetlnff of the AsBOciation, Washincton, 
D.C., May 11-14, 1903. 



28 GENU VARUM AND GENU VALGUM. 

of the normal outrbend in the lower tlurd of the femur. This 
ifl the typical first stage. 

As the deformity progresses and leverage on the long bones 
increases, succeeding out-bends follow, usually in this order: 
first, in the upper third of the tibia, and this bend usually be- 
comes the most pronounced; second, in the lower third of the 
tibia, with a succeeding slight out-curve between these last 
two pronounced bends. 

The changed direction of the axis of the lower end of the 
femur, of course, changes the direction and tilts the normal 
level plane of the condyle. I have described a typical case 
of bow-leg in which the central deformity point — that is, the 
apex of the deformity — ^is in the upper tibial shaft. The only 
logical point of correction, either by osteotomy or osteoclasis, 
is at the apex of the deformity. There the least correction is 
necessary to obtain a perfect result, and the leg can be length- 
ened to the best advantage. 

An occasional exception to the usual rule is when the only 
marked deformity bend is an exaggeration of the normal out- 
curve of the lower femoral shaft. In a bow-leg of this char- 
acter the outer condyle appears to be lengthened and enlarged. 

In a considerable number of skiagraphs I failed to find a 
case in which the condyles deviated from normal except in 
conformity to the altered direction of the lower femoral shafts. 

Another exception to the usual rule of development is where 
the most pronounced deviation from normal occurs in an 
outward bend in the lower third of the tibia. In cases of this 
character a correction at any point far removed from the cul- 
minating point of the deformity cannot give any compensa- 
tory corrective results. 

Fig. 1 is a skiagram of bow-legs, and is selected as illustrat- 
ing several conditions. The child is eight years of age. The 
original bone deformity was undoubtedly an increase in the 
normal out-curves of the femm^, and the secondary tibial 
out-bends subsequently became the most pronoimced. Four 
years of brace treatment have done but little more than to 
slightly correct the deformity by opening up the inner knee 



WALLACE BLANCHARD. 



29 



articulations so that the deformity is nearly doubled when 
standing. Of course, these bones are now too firm to be af- 
fected even slightly by braces, which serve only to enrich the 
instrument-makers and satisfy the parents that something is 
being done. 

The skiagraphic study of genu valgum in various stages 




Fig. 1. 



Fig. 2. 



Fig. 1. Skiafirram of a typical case of grenu vainim, with the central deformity in 
the apper third of the tibia. 

Lktter a indicates the only logical point for over-con-ection. 

Fig. 2. Skiagrram of a typical case of genu valgrum, with the central defonnity 
in the upper third of the tibia. 

Lkttrr A indicates the only logical point for correction. 



clearly demonstrates that, like genu varum, a large majority 
of the cases follow well-defined lines of development, the 
initial deformity being usually an inward bend of the tibia, 
from three to six centimetres, below the head. As the de- 
formity progresses, a distributed inward curve develops 
throughout the remainder of the tibial shaft, accompanied by 
outward rotation. The upper portion of the fibula retains its 



30 GENU VARUM AND GENU VALGUxM. 

normal shape, but develops a sharp inward curve in its lower 
third. The normal space between the tibia and the fibula in 
their lower thirds becomes obliterated. 

With this condition of deformity existing for a considerable 
period, with the body weight transferred to the outer condyles, 
with the external hamstring tendon shortened, and the internal 
hamstring overstretched and relaxed, we have a typical case 
as it is usually presented for correction. 

Skiagraphic observation failed to show any marked devia- 
tion from normal in the condyles. 

The only advantageous point for correction is at the apex of 
the inward convexity and primary seat of the deformity in 
the upper portion of the tibia, where the least operative cor- 
rection is required for the successful obliteration of the de- 
formity and lengthening of the leg. 

Fig. 2 is a skiagram of a typical case of genu valgum. 

Perhaps Professor Lorenz has been chiefly responsible for 
keeping alive the scientific superstition of shortened and elon- 
gated condyles by his operation for genu valgum of over- 
stretching the external hamstring tendon and putting the 
leg in plaster for a month, and in braces for a year thereafter, 
on the theory that the internal condyle would diminish with 
increased pressure, or that the external condyle, when relieved 
of pressure, would elongate, and so correct the deformity. This 
is a theory in direct violation of the now almost miiversally 
accepted law of Wolff. Lorenz^ says that he has recently aban- 
doned this operation, and gives as his reason that "a loose 
joint is to be feared, and, besides, it takes too much time.'' 
As a substitute, he advances central epiphysiolysis as an ideal 
operation, and commends it to the exclusion of all others. 

The apparatus for accomplishing epiphysiolysis is quite 
fully described and illustrated in a paper recently published 
by Dr. Max Reiner,^ assistant at Lorenz's Universitat Am- 
bulatorium for Orthopedic Surgery at Vienna. The apparatus 
used is screwed like a vise to the operating table, and holds the 
lower thigh firmly while the leg is worked like a lever. The 
operator stands with the leg on his right, with the forefinger 



WALLACE BLANCHARD. 



31 



of his left hand in a groove in the apparatus directly under 
the epiphysis, with both hands grasping the knee, with the 
fore-arm resting low down on the outside of the patient^s ankle. 
In this position the operator may throw his entire weight on 
the distal end of the lever, giving him tremendous power. 





Fig. 3. 



Fio. 4. 



Fig. 3. A reproduction of Fig. 6 in Dr. Max Reiner's paper on epiphysiolysis. 
Letter A indicates the opening of the outer half of the joint. 

FiG. 4. A reproduction of Fig. 10 after Reiner. Letter A indicates a separation 
of the epiphysis from the diaphysis. Letters B and C the tilted angle of the head 
of the tibia, and Letter D the uncorrected central deformity in the tibia. 



The operator is directed to alternately increase and relax the 
downward pressure until the deformity is corrected. 

With a view of ascertaining the feasibility of producing 
epiphysiolysis, I have had constructed the fixation apparatus 
from descriptions and illustrations given by Reiner. The 
apparatus accomplishes all that is required of it; that is, a 
perfect fixation. I am convinced that one may occasionally 



32 GENU VARUM AND GENU VALGUM. 

get a separation of the epiphysis, but that the soft parts will 
give way under the stress in a majority of cases before epi- 
physiolysis is accomplished. Of course, a fracture through 
the epiphysis can only be obtained by the leverage power 
transmitted through the external hamstring tendon and liga- 
ments. Which is more likely to occur, a fracture through 
the epiphysis or a separation of the external articulation? 

Reiner answers the question by claiming that he is almost 
invariably successful in disjoining and shifting the epiphy- 
sis, and gives a number of illustrations from skiagrams to prove 
his point. I here present copies of the two most distinct of 
his skiagraphic illustrations. The first. Fig. 3, forty-four 
days after operation, clearly shows that the outer half of the 
joint has been widely separated, sufficiently so, indeed, to 
neutralize a pronounced knock-knee without epiphysiolysis, 
the epiphysis having apparently remained undisturbed, though 
Reiner thinks otherwise. 

The second illustration. Fig. 4, fifty-eight days after opera- 
tion, shows that epiphysiolysis has been accomplished, and 
that the normal relation of epiphysis and diaphysis has been 
shifted. It also shows that the outer half of the articulation 
has been separated, necessitating the over-stretching or rup- 
turing of the external hamstring tendon. This same illustra- 
tion also shows very nicely the central deformity in the upper 
tibial shaft. 

In opening the outer half of the joint and separating the 
epiphysis, the straightening of the leg has been accomplished 
after a fashion, but in bringing the bent tibia to a perpen- 
dicular the uncorrected upper deformity curve in the tibial 
shaft has tipped the tibial head to an angle of 45°. 
It is possible that a year or two in plaster of Paris, dressings, 
and iron braces may assist nature in welding this aggregation 
of malpositions into a leg that may possibly be symmetrical 
and serviceable, but it is rather more than doubtful. 

Reiner says that, when attempting epiphysiolysis, he occa- 
sionally gets an infraction above the epiphysis. I have fre- 
quently used the Grattan osteoclast with one resistance bar 



WALLACE BLANCHARD. 33 

placed against the condyle below the epiphysis and the second 
resistance bar about six centimetres above, and have invari- 
ably found that I obtained an osteoclasis in the shaft as 
remote from the epiphysis as the upper resistance bar would 
allow. 

In my experience the lower end of the femoral shaft re- 
mains friable, and will bend without fracture six or eight 
years after eburnation has become so complete that the tibia 
will fracture with a loud snap. 

Reiner places the limits of age for epiphysiolysis at from seven 
years to seventeen and a half while Lorenz places it at from 
five to sixteen years. 

Reiner practically admits the frequent inefficacy of the opera- 
tion when, in closing his paper, he says, "There is danger of 
the return of the deformity after the removal of the plaster 
bandage, in which case apply retention apparatus for a pro- 
longed period." 

Since the central point of the deformity is usually in the 
upper third of the tibial shaft, central epiphysiolysis, even 
if accomplished, is a misnomer. The term "eccentric epi- 
physiolysis" would be more appropriate to the operation, 
which, at best, is only the production of a deformity in one 
bone to offset the deformity in another. 

Epiphysiolysis, like the bloodless reduction of congenital 
hip dislocation, is of Italian origin. Dr. Codivilla, of Bologna, 
reported on a large number operated upon in this matter be- 
fore the adoption of the method in Vienna. 

An occasional exception to the general rule of development 
of genu valgimi is seen in the partial or entire obliteration 
of the normal out-curve of the lower third of the femur, and 
the out-curv'^e may become absolutely reversed. This changed 
direction of the lower end of the femur produces a misleading 
appearance of elongated inner condyles. The normal level 
of the condyles and articulations have been tilted several 
degrees. Even in these cases the deformity is not central in 
the condyles or articulations, but at the abnormal bends in 
the femoral shafts above. In these cases the only logical 



34 GENU VARUM AND GENU VALGUM. 

point of correction is at the centre of deformity. After the 
correction has been made and the normal direction of the 
femur has been restored, it will be found that the condyles 
are normal. 

In these cases, if in any, epiphysiolysis would be permis- 
sible, though I believe the operation to be most unfortunate 
when most successful; and it remains to be proven that the 
separation of the epiphysis dqes not endanger bone develop- 
ment. After two trials, in which I have faithfully followed 
Reiner's method, I have only succeeded in over stretching the 
external hamstring and opening up the outer half of the Joint. 
The operations were followed by considerable swelling and 
severe pain, and I do not feel justified in continuing the use 
of so dubious a procedure. 

Another rare exception to the rule in genu valgum is where 
the chief deformity is an inward bend in the lower half of the 
tibia. Here, also, the only logical point of correction is at 
the apex of the deformity. 

Osteotomy is undoubtedly the most popular operation for 
the correction of severe rachitic deformities of the legs, yet 
it has many disadvantages when compared with osteoclasis 
performed with the aid of the perfected Grattan osteoclast. 
Some of the disadvantages are: time required for operation; 
the danger of infection, which, though it may be slight, never- 
theless exists; time, care, and expense necessary for anti- 
septic precautions; and the pain that always accompanies 
an open wound. But the most serious objection to osteotomy 
is the delayed union as compared with union after osteoclasis. 
This is undoubtedly due to the severing of the continuity of 
the bone shaft and the carrying of soft tissue into the open 
space with the chisel. This delayed union has frequently 
to be supplemented by post-operative treatment, which is 
never required after rapid osteoclasis. 

Rapid osteoclasis, as practised at the Home for Destitute 
Crippled Children in Chicago, may be briefly described as fol- 
lows: Ether is administered so rapidly that in two minutes 
the patient is ready for operation. The bending or breaking 



36 GENU VARUM AND GENU VALGUM. 

of the bone in the osteoclast rarely takes more than six or eight 
seconds. The deformity is over-corrected by hand and held 
while a plaster bandage is applied. Seldom more than five 
minutes is consumed in the application and setting of the 
plaster bandage, and eight minutes suffice for the anaesthetic 
and operation, and the patient is removed from the table. 
The brevity of the anaesthesia necessitates the administration 
of but a small quantity of ether, permitting the patient to escape 
nausea and vomiting; and the rapidity of the operation is 
necessary to preserve the soft parts from bruising. 

In bow-leg, with three contributing curves, the apex of the 
most prominent is usually selected for the operative point, 
and over-correction is made not only sufficient to correct the 
curve attacked, but continued sufficiently to neutralize the 
two minor deformity curves. 

Fig. 5 represents a severe case of bow-leg. The only opera- 
tion was an over-correction of the tibia just above the middle, 
in the apex of the deformity. The skiagram of this case. Fig. 
6, shows that the two minor curves and the over-correction 
curv^e, though pronounced, have neutralized each other. The 
over-correction has lengthened the legs about six centimetres, 
and, as will be seen in Fig. 7, has assimilated into the general 
contour of the legs, producing a perfectly symmetrical appear- 
ance. 

To illustrate knock-knee correction to the best advantage, 
I have selected a bilateral case, as will be seen in Fig. 8, the 
only deformity being in the left tibia, about three centimetres 
below the head. In this case the only operation was an osteo- 
clasis at the apex of the deformity in the tibia, with slight 
over-correction. The result will be seen to be perfect, both 
in the skiagram. Fig. 9, and the photograph taken six weeks 
after the operation. Fig. 10. By comparison of the two legs 
in the skiagram, it will be seen that there is practically no dif- 
ference in thecondyles. 

Rapid imions are the invariable rule following osteoclasis, 
and in six weeks after the operation the patient is walking 
on straight legs, without braces of any kind. A record of 



38 GENU VARUM AND GENU VALGUM. 

five hundred cases without a single abrasion, delayed union, 
or other unsatisfactory result, would seem to prove that rapid 
osteoclasis is a safe and certain operation for the correction 
of genu varum and genu valgum, and that it is free from com- 
plications. 

In conclusion, skiagraphic observation seems to prove that 
the deformity of knock-knee and bow-leg is seldom, if ever, 
central in either the condyles or the joint. 

I feel constrained to say that epiphysiolysis is hardly worthy 
of serious consideration, when compared with either oste- 
otomy or osteoclasis, that osteotomy has some slight dangers 
from which osteoclasis is free, and the comparatively pro- 
longed time taken for bone union and recovery should con- 
demn it when osteoclasis is available. 

Bibliography. 

1. Lorenz. Medical Record, Xew York, December 27, 1902. 

2. Reiner. Zeitsclirift fiir orthopadische Chirurgie, XI. Band. 

DISCUSSION. 

Dr. Augustus Thorndike, of Boston, said he had been very much 
impressed with this device of Dr. Taylor's, for it seemed to more nearly 
imitate the production of a fracture by natural processes than any other 
osteoclast hitherto invented because of the rapidity with which it 
worked. The mechanism was worthy of great commendation. 

Dr. John Ridlon, of Chicago, said that this apparatus of Dr. Taylor 
was a beautiful apparatus. He had used his own instrument, modelled 
after this plan, and had torn the flesh of the limbs in two instances, 
and he no longer employed it. He >vould criticise the apparatus pre- 
sented by his own experience. The leg pieces in that apparatus were 
covered with thick rubber tubing such as was found under elliptical 
springs in heavy wagons, and he was sure that the padding in this 
apparatus presented, as in his own apparatus, would cause the skin to 
-catch and not slip on the hooks, and this, he was sure, was the cause 
of the tearing of the skin. The hooks should be of polished metal, and 
round, as in the (Irattan osteoclast. In several hundred operations 
<lone by Dr. Blanchard and himself under such conditions the skin had 
not torn. He also believed that the round or elliptical bearing pad 
would break the bone more easily and certainly at the desired point 



DISCISSION. 39 

than the flat breaking pad. The apparatus presented was certainly 
ingenious and much less expensive than the Grattan osteoclast. 

Dr. Henry Ling Taylor, of Xew York, said he had been very 
much impressed with both papers. The first paper was an exceedingly 
valuable contribution to the subject. The idea of breaking the bones 
below the knee for knock-knee was new to him, and he was not aware 
that this had been done except in special cases: hence this point was 
certainly one of great importance. If the cases all resulted as well as 
those cited, it would seem that a great advance had been made. The 
osteoclast which he used was the Grattan instrument modified by Drs. 
Phelps and Weigel, and with it he had found it rather diflicult to pro- 
duce the fracture in close proximity to the joint. In httle children the 
fracture usually occurred not far from the centre of the tibia: fortu- 
nately, this point of fracture seemed to aiford sufl[lcient compensation in 
most cases. Another point of some importance in the correction of 
bow-legs was the inversion of the foot occurring in nearly all these cases. 
Apparently, it was due to a rotation or twist in the shaft of the tibia, 
which was usually overlooked in operating. The tibia was ordinarily 
straightened and put up with the curve straightened, but with this twist 
unstraightened. Such cases recovered with the bow-legs cured, but with 
the feet turning quite markedly. In operating, one should take pains to 
manipulate the fragments until quite free, and then give the lower frag- 
ment a strong outward twist. He had adopted this plan in the past year 
or two, and with better results. There was another reason for doing 
this; I.e., that with the outtuming foot the strain was in the proper 
direction to prevent recurrence of the deformity. The osteoclast shown 
seemed to him an exceedingly workmanlike instrument, but he agreed 
with the criticism that the hooks would probably work better without 
padding. If it did better work than the improved Grattan osteoclast, it 
would be a remarkably fine instrument. 

Dr. W. K. TowNSENB said he had had the pleasure of seeing this 
new instrument work, and it certainly did the work quickly, accurately, 
and eflSciently. The suggestion made by Dr. Kidlon was a good one, 
for he had noted a slight catching of the skin. This instrument, when 
perfected, might take the place of the heavy and more expensive in- 
strument of Grattan, with which there was always some difliculty in 
releasing the screw with sufficient rapidity. 

Dr. H. A. Wilson said he would like to ask if Dr. Blanchard had 
used the osteoclast in bending the bones in their entirety in addition to 
the production of the fracture in the extremities; in other words, 
whether both processes had been used in the same patient. In the 
first skiagram with the long curve he thought a good deal could be 



40 GENU VARUM AND GENU VALGUM. 

gained by bending the entire bone first, and then producing a fracture. 
With reference to the various forms of appliances for the production of 
fractures without cutting, he had a distinct recollection of having seen 
the skilful production of fractures by hand manipulation alone by 
Dr. Townsend, which had demonstrated to him the advantage of a very 
rapidly working instrument. The Grattan osteoclast seemed to him 
hardly rapid enough in its action. It looked as if this new instrument 
of Dr. Blan chard would be an improvement in this particular. 

Dr. Blanchard said, in reply to Dr. Wilson, that in the work done 
in Chicago by Dr. Ridlon, this had been done in the Home for Crippled 
Children. Many cases that seemed to be impossible of treatment by 
hand had been very successfully treated by Dr. Ridlon by hand manipu- 
lation. It could be done by one with sufficient muscular power. Fre- 
quently in cases on which they started to do osteoclasis it was found 
that the bones would bend quite easily, and that this bend could be dis- 
tributed throughout the entire shaft of the bone. The limb could then 
be put up in plaster of Paris with perfect result.- Frequently, however, 
in cases of knock-knee the fracture of the Grattan osteoclast occurred 
exactly at the desired point. If one resistance bar were nearly opposite 
the pressure bar, and the other considerably removed therefrom, the in- 
strument would work very accurately. It seemed to him that one ob- 
jection to the new Taylor osteoclast was that the leg supports would 
tend to spring outward and so favor the laceration of the soft parts. 
The conception of the instrument was excellent ; but he would suggest 
replacing these spring resistance bars by very heavy bars, also the re- 
moval of all padding. 

Dr. R. TuNSTALL Taylor thought all the members must feel very 
grateful to Dr. Blanchard for his study in this field. The idea of hav- 
ing the leather padding sliding on the resistance bars was that, if the 
leather adhered to the skin, the two would move together on the bars 
and so obviate any tearing of the skin, but the instrument was practi- 
cally as safe without it. The apparatus could all be taken apart and 
packed flat in a dress-suit case. For knock-knee two resistance bars 
could be placed on one side. 



VI. 

THE OCCURRENCE OF PAINFUL AFFECTIONS OF 
THE FEET AMONG TRAINED NURSES. 

A Series of 500 Observations upon Normal and Disabled Feet, 



The liability of trained nurses to develop some static trouble 
with their feet during their hospital service is well known. 
In large hospitals it becomes a matter of economy to limit 
this so far as possible, and the following investigation was 
undertaken by me in a large general hospital in the hope of 
diminishing the trouble by seeing that all nurses wore during 
their course of training a proper boot, and were placed, so far 
as possible, imder conditions favorable for their feet. With 
this in view, every nimse entering the hospital was examined 
soon after entrance, boots of a suitable shape were prescribed, 
and, if trouble with the feet arose during the course, she was 
seen and prescribed for. 

The number of nurses observed having reached 500 in the 
course of some eight years, it has seemed worth while to analyze 
the records of these observations. In addition to any informa- 
tion to be derived about the etiology of this acute form of 
static trouble of the foot, there are certain questions of specific 
interest to hospital superintendents, poUce commissioners, 
and civil service examiners, which might well be elucidated 
by this mass of material. These questions are in part as fol- 
lows: — 

1. Can it be told by examination whether the feet of an 
individual are likely to break down or not under the strain of 
constant use? 

2. What are the factors in causing this breaking down? 

3. What is the nature of the process giving rise to the pain- 
ful condition? 

Presented at the Seventeenth Annual Meeting of the Association, Washing- 
ton, D.C.. May 11-14. 1908. 



42 PAINFUL AFFECTIONS OF THE FEET. 

4. How much may be done toward preventing it by the use 
of proper boots? 

The material at my command consisted entirely of young 
women between the ages of twenty-three and thirty-five. 
They were presumably healthy, having been selected from a 
large number of applicants who had answered a number of 
questions with regard to their general health when they filed 
their applications for admission to the school. The majority 
of them had previously earned their own living, having been 
school-teachers, housekeepers, nurses or attendants in other 
institutions, stenographers, and the like. Many had, how- 
ever, lived at home, with no occupation. 

During one period of a few months the nurses were not ex- 
amined at entrance, but were fitted to regulation boots in a 
routine way, and only seen by me if they had trouble. But 
under these circumstances the percentage of trouble was higher 
than when they were examined at entrance and prescribed for 
individually, and that method was abandoned. With the 
exception of this time, during which no records were kept, and 
of another period of a few months when the work was under- 
taken by a substitute, the 500 nurses have all been seen by 
me and prescribed for individually, and the series of observ-a- 
tions is continuous. 

The conditions of their life in the hospital are of importance. 
The prol)ationary period is two months, the course itself two 
years. The nurses on the average work nine and a quarter 
hours, with two hours off during the day. They do not live 
in the hospital building, but in a modern, well-ventilat-ed 
dormitory near the hospital. There are now about 150 nurses 
in the school, but when the inquiry was begun the school con- 
tained only about 115. There have, therefore, been under 
my observation for eight years, at all times, from 115 to 150 
young women living under conditions entailing great strain 
on the feet. Having records of all these cases along w^ith care- 
ful notes of the nurse's condition at entrance, I have been 
in a position to estimate the value of certain things observed 
in the feet at entrance, and also the chance of familiarizing 




Fig. 1. Pronated foot without breaking down of the arch. See tracing. 




Fig. 2. Patient standing on glass table with a mirror undenieath. On theluiirror 
is seen the weight-bearing surface of the foot. 



44 PAINFUL AFFECTIONS OF THE FEET. 

myself with the ordinary type of trouble as it occurs in these 
nurses, of studying its character and progress, and of attempt- 
ing to shorten its course. 

Method of Examination, — Imprint tracings were first used 
by having the nurse step on smoked paper, but after 130 of 
these observations it became evident that they were practically 
worthless. An imprint of this sort is a composite record of 
two positions. The foot first touches the paper and records 
the non-weight-bearing imprint, and then the imprint of the 
weighted foot. The two are merged, and a foot, which in use 
really rests upon two points of pressure only, the ball of the 
foot and the heel, gives a mark as if the outer border touched 
also. This outer border touches at first, then lifts under weight 
(Fig. 1). The imprints not only gave no reliable information 
as to the durability of an individual foot, but, when studied, 
showed in most cases that they were made up of two super- 
imposed impressions, and must be misleading. The method 
was therefore abandoned. 

A plate of glass with a mirror placed at an angle underneath 
was from that time used in all examinations. The nurse 
was examined with her feet bare, facing the observer, on a 
glass plate raised 18 inches from the floor (Fig. 2). In her 
natural standing position the anemic weight-bearing surface 
of the feet was observed through the glass, being reflected in 
the mirror. The pressure surface was recorded by a pencil 
sketch in the record. These contact surfaces followed the 
same three types shown in the figures of the smoked tracings 
(Figs. 3, 4, and 5). By inspection of the feet from in front 
the degree of rolling in (pronation) of the foot was next noted 
and recorded as the nurse stood in a natural position. The 
condition of the circulation of the feet was noted in many cases, 
whether congested with distended veins or not. Calluses, 
bunions, crumpled toes, ingrowing nails, and other signs of 
abuse were noted. Finally, the general appearance of the 
foot and an estimate of its probable usefulness was recorded 
as excellent, good, fair, suspicious, or poor. Each nurse was 
then given a note to a retail shoe store with suggestions as 




Fig. 3. Tracing of a flat foot. No symptoms, foot useful. 




Fig. 4. Tracing of a foot resting on two islands. No symptoms, foot useful. 



46 PAINFUL AFFECTIONS OF THE FEET. 

to any modification recjuired in fitting her to the regulation 
boot. 

Value of the Examination in determining the Durability of 
the Feet of an IndividuaL — In forming the opinion expressed 
in the tenns "excellent," "good/' "fair," etc., I was guided 
by the general appearance of the foot, chiefly whether or not 




Fio. 5. Type of tracing described as normal, with outer border touching: ground. 

it was pronated nmch, the condition of the circulation, the 
degree of flexibility to dorsal flexion in passive manipulation, 
and the nurse's previous history. 

In analyzing the records, I took the consecutive histories 
of a certain number of nurses who had during their course 
trouble of enough importance to lead them to complain, and 
of a similar number of nurses who had no trouble, and compared 
the later histories of the nurses of the two groups. The figures 
are given in percentages: — 



ROBERT W. LOVETT. 



47 



Excellent . 
Ciood . . . 
Fair . . . 
Questiouablo 
Poor . . . 
Not classed 



Nurses bavins 
trouble. 



12%) 

2H% [ (m 

20%) 
12^.) 
10^; y 40% 
18%) 



Nurses bavins 
no trouble. 



0% ) 
2fJ% Y (52% 
30% ) 
12% > 
10% [ 38% 
10% ) 



It will be seen that my opinion of the usefulness of the foot 
formed in this way was of no practical value in selecting the 
cases likely to give trouble. To reject applicants on an opin- 
ion formed by inspection would be unsafe. There have been 
five or six nurses with perfectly flat feet to go through the 
school without any trouble. There have been many nurses 
with the most unstable and threatening feet, which were badly 
pronated and bore heavily on the inner side of the ball of the 
foot and on the heel, who have gone through the school with- 
out discomfort, whereas nurses with feet in perfect relation to 
the leg according to all accepted ideas have been speedily 
incapacitated. 

Weight and Size of Boot. — A series of 60 observations were 
made as to the relative weight of the nurse and the size of 
boot worn, to see if the relatively small feet were the trouble- 
some ones. The nurse was asked in each case what her weight 
was, and what was the size of her boot. Of the nurses having 
trouble, the average weight was 132 pounds and the average 
boot No. 5. Of the nurses having no trouble, the average 
weight was 131 poimds and the average boot No. 5. It was 
evident that no information was to be obtained from this 
line of inquiry. 

Pronation, — The amount of pronation or rolling in of the 
foot was investigated (Fig. 6). It is generally assumed that, 
although a certain amount of pronation is normal in weight- 
bearing, more than a moderate amount is an evidence of weak- 
ness in the foot and predisposes to breaking down. The figures 



48 



PAINFUL AFFECTIONS OF THE FEET. 



to be quoted do not bear out the opinion that decidedly pro- 
nated feet are necessarily likely to break down under strain. 




Fig. 6. Normal and pronated position of the foot, the latter in dotted outline. 



This fact explains in a measure the foregoing statement that 
the estimate formed by inspection was of little value; for, 
influenced by general opinion, I was led to regard pronation 
as the most important factor in forming my opinion. The 



ROBERT W. LOVETT. 



49 



estimate of pronation was made by the eye, and was recorded 
when the nurse was first seen. 

The table consists of the consecutive records of 185 nurses 
analyzed later to see what proportion of nurses who had trouble 
and who had no trouble had pronated feet when they entered. 

In a general way the percentage of trouble was slightly 
higher when much pronation was present (23 per cent, as con- 
trasted with 17 per cent.) 7 and slightly lower when there was 
little or no tendency to pronation (40 per cent, as contrasted 
to 43 per cent.). But such a slight difference shows that the 





NunM without 


Nnneawith 
trouble. 


Pronation marked 

Pronation more than average . . . 
Pronation average or moderate . . 

Pronation slight 

Pronation very slight 

^0 pronation 

Not noted 


4%; '^ 

30% 

17% > 

1.2% 


a6% 
20%) 

10% ^40% 
10% i 
7.6% 


Feet flat 







d^ree of pronation or ''weak foot" is of little practical value 
in forming an estimate of the usefulness of an individual foot. 

Pressure Areas an Glass. — ^The only sign observed at the 
first examination that seemed to be of prognostic value was 
the imprint of the nurses' weight-bearing foot as observed 
through the glass plate. The nurses showed three types of 
pressure areas: (a) when the foot rested on two islands, one 
under the heel and one under the ball of the toe, while the outer 
border did not bear weight (this type was classed as "two 
islands"); (b) when the outer border bore weight as well as 
the heel and front of the foot; (c) when the foot was more or 
less flattened and the outer border was very broad. 

150 nurses were classed as follows: — 



50 



PAINFUL AFFECTIONS OF l^E FEET. 





Both feet 

••two 
iBlands/' 


One foot 


Botb^t 


^ 


NurseB having trouble , . . 
NturseB having no trouble 


68% 

42% 


18% 
16% 


18% 
88% 


6% 
2% 



It will be seen that nurses whose feet bear weight along the 
outer border are less likely to have trouble than when the weight 
rests on two pressure islands. 

Flexibility of the Foot, Circulation, etc. — ^The degree of flexi- 
bility of the foot in passive dorsal flexion proved not to be 
a sign of prognostic value, nor did disturbance of circulation 
in the foot, as shown by congestion and distention of the veins 
at the first examination, signify anything of importance, as 
at the beginning of the training such a disturbance was common. 

The index of pronation of the foot, as measured by an in- 
strument devised by Dr. F. J. Cotton and myself, did not prove 
of the value that we had hoped * (Fig. 7). 

In 21 cases measured by this instrument the index averaged 
as follows: — 



Nurses without trouble 
Nurses with trouble . 



Right foot supinated. 
Right foot pronated. 
Right foot supinated. 
Right foot pronated. 



60 L. F. 61. 

63 L. P. 66. 

68 L. P. 61. 

62 L. P. 66. 



Much to my regret, therefore, I am obliged to record the 
fact that the original examination has proved of little value, 
so far as it indicates whether the feet of an individual nurse 
are likely or not to give trouble under the severe strain of use. 
The only point to which much importance can be attached 
is the character of the imprint on glass. The examination, 
however, is, I believe, of great value in suggesting precau- 
tions which may be taken which will be spoken of later. 

*Loyett and Cotton, **8ome Practical Points in Anatomy of the Foot," Boeton 
Medical and 8ta*ffical Journal, Auffust 4, 1898. 



ROBERT W. LOVETT. 



51 



Nature of Process. — ^The character of the disturbance when 
it occurred was next investigated. 

Symptoms were of a pretty imiform character. Burning 
and a full feeling in the feet were succeeded by lameness and 
stiffness. Swelling of the feet and some restriction of the 
normal motion followed in the severer cases. These symptoms 
in favorable cases imder proper treatment unproved and dis- 




Fio. 7. AiqoaratQfl for estimating index of pronation. The angle to be measured 
is A« B, G. 



appeared. In certain cases, however, in spite of proper sup- 
port, massage, douches, etc., these increased imtil the nurse 
was incapacitated from work for a few days. Tenderness 
appeared in nearly all these cases, either imder the scaphoid 
or imder the bottom of the heel, rarely in the great-toe joint. 
Pain in the knees and back were not imcommon symptoms. 
Rare symptoms were synovitis of the tendo Achillis, and only 
in one or two cases was there complaint of pain in the front 
of the foot, and these seemed to be traimiatic. 



Januaiy 


. 8% of aU cases. 


July ... . 


Febniaiy 


.14% « « ' 


August . . . 


March . 


. 24% " 


^^ September . . 
f^-^ October . . . 


April . 


. 10% " 


May . . 


. 16% " 


J November . . 


June 


. 6% " 


December . . 



62 PAINFUL AFFECTIONS OF THE FEET. 

Change in Imprint, — ^The essential character of the static 
change causing the trouble was investigated and proved to be 
a moving inward of the bearing surfaces as seen through the 
glass, in a few cases observed no change had occurred, and the 
imprint was the same as at entrance. It seemed generally as 
if the muscles relaxed and allowed the foot to roll in. Real 
breaking down of the arch of the foot in nurses having trouble 
was not observed in any case. 

Season of Year. — ^It became evident that nurses were more 
liable to have trouble at certain seasons than at others. The 
cases classified by months are as follows:—: 

. 4% of all cases. 
. 2% " «♦ 
. 0% «« « 
. 0% «* " 
. 8% " 
.6% " 
64% of all cases occurring in Februaiy, March« April, and May. 

Time at which Trouble occurs. — Inquiry as to the period 
of the nurses' training at which trouble hegeax gave the follow- 
ing result: — 

At once 2% Four months 6% 

One month 16% Six months 6% 

Six weeks 4% Nine months 2% 

Two months 20% Twelve months 2% 

Ten weeks 12% Twenty-four months .... 4% 

Three months 28% 

It will be seen that 60 per cent, of all cases of trouble occurred 
in from two to three months after entry. As the nurses are 
admitted more or less equally through the year, it will be seen 
that there is another etiologic factor beside the seasonal one 
jiast mentioned. 

Conditions preceding the Trouble. — ^In nearly half of the cases 
no definite cause could be assigned for the trouble. The ab- 
normal conditions preceding the trouble mentioned in the 
order of frequency were as follows: tonsillitis or diphtheria, 
rheumatism, change in work, improper boots, confinement to 



ROBERT W. LOVETT 53 

bed, excessive heat, neurasthenia, trauma, amenorrhoea. Nurses 
seemed inclined to experience their first trouble during men- 
struation rather than between the periods. 

The relation to rheumatism seemed of much interest. Three 
or four perfectly typical cases of trouble in the feet occurred 
in nurses previously free from rheumatism. These cases all 
proved resistant to ordinary supporting treatment, but in 
a few days developed signs of general rheumatism. No diag- 
nosis of rheumatism was made in this connection unless the 
symptoms appeared in the upper extremity, as in the hips 
or knees they might have been purely irritative and due 




Fig. 8. Photograph of a nurse who broke down after tliree months, and who has 
been incapacitated from work for two months. In this ease the foot appeared to be 
80 sTood that the regulation boot was not ordered {American Medicine). 



to the abnormal use of the foot. There was nothing to dis- 
tinguish them from the ordinary painful affection in the be- 
ginning, but in their later course they proved obstinate and 
long continued. Such patients required support to the arch 
as much as if the affection were purely static, and derived as 
much comfort from it. 

Another point of interest is that when trouble with the feet 
occurred during a long period of amenorrhcea it was apt to be 
most troublesome. In one nurse in a period of severe discom- 
fort, diu-ing which she was barely able to get about the ward, 
menstruation came on, and the trouble at once improved. 

Period of Disability. — When it became necessary to take 
a nurse off duty, it was not done, of course, until it seemed 
that she would not recover by the use of a proper support 
while at her work. The period of disability lasted in most 



54 PAINFUL AFFECTIONS OF THE FEET. 

cases from two to three weeks. It always seemed at the be- 
ginning as if it would be less, but continued experience showed 
that, if a nurse had once experienced severe trouble, it was 
wiser to keep her off duty until the tenderness in the foot had 
practically disappeared. 

No statistical inquiry has been attempted as to the number 
of nurses having trouble or incapacitated each year, as it would 
have involved much more labor than it would have been worth. 
The causes of removing a nurse from duty are often compli- 
cated, and any such inquiry would have necessitated a search 
into the nurses' record in each case as well as into my own 
records. A fair statement of the case would be that for the 
last five years some nurses have each year been incapacitated 
from duty. During these years in a few cases nurses have 
left the school on account of continued or recurring disabil- 
ity in their feet. 

The evidence so far adduced points rather to the general 
condition of the nurse than to the especial structure of her 
feet as the cause of the trouble. They have trouble in the 
spring when they have been housed all winter and when the 
work in the hospital is hardest. This trouble is more likely 
to come between the second and third month of their course 
than at any other time, when the novelty of the situation 
has worn off, and the fatigue of the routine begins to be felt. 
The trouble is likely to follow diseases which debilitate the 
muscles. 

Bootfi. — It is a matter that would be admitted without dis- 
cussion that, if a person is to undergo a severe test to the foot 
in the matter of standing, a good boot is better than a 
bad one. The chances of enduring the strain successfully 
would be diminished by wearing a tight boot with a pointed 
toe, a high heel, and a slender flexible shank. 

At the time that these observations were begun there was 
no ready-made boot for women in the market worthy of seri- 
ous consideration. It was, therefore, necessary to have one 
constructed on new lines, and in the boot devised and used 
since that time the following points were aimed at: (1) The 



ROBERT W. LOVETT. 55 

boot shoukl be as wide as the foot in front. (2) The inner 
edge of the front of the boot should be nearly straight, so as 
not to displace the great toe outward. (3) The boot should 
be constructed on a slightly curved line, the convexity being 
outward so as to hold the foot in its position of strength. (4) 
The shank should be fairly high and slightly stiff. 

These propositions were submitted to a firm of shoo dealers, 
and a last made on these lines. This boot has been used by 
these nurses, and has not been radically changed. At first it 
was made a little too much curved, and was apt to cause corns 
on the little toe. At one time the shank was made stiffer, 
but shortly after this there was a good deal of trouble among 
the nurses, and I returned to the original shank. But this 
outbreak of trouble was coincident with increased duty on 
account of the admission of soldiers returning from the Span- 
ish War, and was probably due to that. The boot is not ideal, 
and may not be the best for the purpose, yet I have felt that 
experiments were risky, and that I had at least a fair boot, 
the working of which I understood. My aim, in short, has 
been not to cramp the foot in front, to support the arch under- 
neath, and to hold the foot slightly curved. 

The difficulties have been to get the shoe dealers and the 
nurse to agree on a boot sufficiently wide in front, and to get 
the manufacturer to make the last deep enough where the 
upper of the foot joins the vamp in front. The transverse 
seam below the lacings has been on the whole too tight and 
a source of much trouble. If it is made too loose, the front of 
the boot wrinkles, and the regulation boot and most others 
are too shallow where the upper joins the vamp in front. In 
each case the nurse has been given a letter stating her re- 
quirements, and the instructions to the dealer have been that, 
if she could not be fitted properly, she nmst have a boot made 
on the same general lines, but suiting her especial reciuirements. 
In perhaps 250 nurses the boots were inspected before being 
worn, but the system was abandoned on account of certain 
practical difficulties, and since then the nurses' instructions 
have been to report if the boot was not comfortable. Lace 



w^ 



II 



U ^ 



> 5 



.t: s. 



II 



^ C8 

C — 

S. as 
■«-» ** 

O V- 

,:= o 

si 

2 " 



ROBERT W. LOVETT. 67 

boots are ordered with rubber heels, and low shoes are not 
allowed except by special permission in selected cases. The 
boots are made of kid, with a sole of medium thickness. The 
shank is stiffened by a light piece of spring steel, and the heel 
is of medium height. 

In 130 nurses I made outline tracings of the foot and of 
the boot worn at entrance, and in practically all cases the re- 
sult showed a gross disproportion between the size of the boot 
and the foot. Of later years the style of boot worn at entrance 
has improved; and there are now in the market several styles 
of cheap boots which conform fairly well to the theoretic re- 
quirements. At one time when a nurse came to the hospital 
wearing a good boot which seemed to meet the requirements, 
I did not order regulation boots, but allowed her to wear what 
she had. But the experience was not favorable to the method, 
and the proportion of trouble in such nurses was imduly large, 
and now the regulation boot is prescribed except in very ex- 
ceptional circumstances. 

It is a very common experience to have the slight trouble 
which very often occurs in the first days of duty immediately 
relieved on putting on the regulation boot. The outcome 
of my experience has been that I believe that a good boot di- 
minishes trouble, but cannot prevent it, and that, if nurses 
were allowed to wear boots of their own selection, there would 
be much more trouble than there is now; that, as the cause 
of the trouble seems most often to be foimd in muscular re- 
laxation due to fatigue and similar causes, the problem is 
so far as possible to supplement the action of the muscles in 
holding the foot in its supported position. 

Prevention of Trouble. — ^At the first examination, if the nurse's 
boot was trodden over to the inside, or if much pronation was 
present, the inner side of the sole and heel was made one-eighth 
inch or even one-fourth inch thicker than the outer side in 
order to tip the foot over onto its outer border somewhat. 

Continued experience has not shown that this is a measure 
of much value, and its preventive effect was small, and in the 
last year or two it has been used much less than at first. If 



68 PAINFUL AFFECTIONS OF THE FEET. 

the nurse's foot showed a very high arch, an order was given 
for a boot with an extra high shank. In some of these cases 
a cork pad was put in at the beginning to support the high 
arch. In a few cases of very severe pronation, and in one 
case of traumatic flat foot, metal supports have been put in 
when the niurse was first seen, with apparent prevention of 
trouble. 

Treatment. — ^Every nurse has been asked to report at once 
any discomfort in the feet, but the disposition has been to put 
off ''making any fuss" until the condition had existed some 
days at least. 

In the milder cases the aim of the treatment has been to 
relieve the muscles from strain and to stimulate the circula- 
tion. Felt pads have at once been put in the boots to support 
the arch, and the nurse has been ordered to soak the feet in 
hot water at night for ten minutes, and then to shower the 
feet with cold water, and to bandage the feet and legs with 
flannel for the night. The majority of early cases have, I 
think, yielded to this treatment. If, however, rapid improve- 
ment has not come on in two or three days, or, if the first symp- 
toms have been severe, a metal support to the arch of the 
foot has at once been put in and measures to stimulate the 
circulation have been used, as described above. In some 
cases plates have relieved the symptoms at once, and have 
been worn for a few weeks or months, generally to be given 
up later. 

In the severest cases all sorts of expedients have been tried 
to cure the pain while the nurse continued her work. The 
most efficient support of all is to apply a felt pad to the instep 
while the foot is held inverted by fastening the pad to the 
bare foot by several straps of adhesive plaster which pass from 
the outer border of the foot imder the foot and up under the 
inner side of the arch over the top of the foot to the ankle. 
These straps overlie each other, and are covered by a heavy 
cotton bandage. This dressing must be renewed every day 
or two. This dressing, which is distinctly more supporting 
than any metal plate, has in some cases carried nurses over 



ROBERT W. LOVETT. 



59 



a painful attack while on duty, but more often it ha^ failed 
in the severest cases. In these severest cases hot air baths, 
massage, and stretching of the calf muscles have been faith- 
fully tried with no brilliant success. They have helped the 
condition, but I cannot recall a severe case in which any one 
of these latter measures has made any serious difference. 

If a proper fitting metal plate fails to relieve symptoms 
within two or three days, the sooner the nurse is laid off, the 
better, and the shorter her period of incapacity. When she is 
laid off, she is not allowed to walk; but, as she convalesces. 





FiG.U. Feet and boots, typical traoinffs. The boots are shaded. 



she is encouraged to take out-of-door walks, and is not re- 
garded as fit for duty imtil she can walk a mile or two on brick 
sidewalks without pain. Several times it has been demon- 
strated that it was imwise to allow nurses to go on duty 
under other conditions. Strychnine in fairly large doses has been 
used in a number of cases in the hope of improving the mus- 
cular tone when trouble was threatening, but I have failed 
to see striking instances of its benefit. 

In no case can I recall that a metal plate has been other- 
wise than helpful. It is often not enough to prevent laying 
off of the nurse, for the tramnatism of constant walking and 
standing is too great for it to overcome, but as a preventive 
it is of great value and a great aid in protecting from strain 



60 PAINFUL AFFECTIONS OF THE FEET. 

convalescents from foot trouble. A few nurses have contin- 
ued to wear plates throughout their course, but the majority 
have dispensed with them after a while. 

A summary of this paper can perhaps best serve its purpose 
by attempting to answer the questions proposed at its be- 
ginning: — 

1. It has not been possible to tell with any certainty by 
examination whether or not the feet of an individual are likely 
to give trouble. The only reliable information obtained in 
these cases was given by the imprints seen through glass. A 
foot with a well-distributed pressure area seemed rather less 
likely to give trouble than one resting on two islandsi the de- 
gree of pronation, the condition of the circulation, the relative 
weight of the nurse, and the dorsal flexibility of the foot all 
proving of little or no value as elements in prognosis. A 
flat foot may be perfectly serviceable, as may also a severely 
pronated one, while an apparently well-balanced foot may 
become painful. 

2. The factors in causing the trouble among the nurses were 
to be sought rather in the general conditions than in any espe- 
cial conformation of the foot. It followed in many cases 
illness and other conditions causing muscular debility. It 
occurred in most cases from two to ijaiee months after entrance, 
and it began most often in the early spring when the nurses 
had been indoors all winter, and least often in the fall. 

3. The trouble was caused by a rolling in of the foot and 
a shifting inward of its weight-bearing areas, and not in any 
case observed by a breaking down or even lowering of the arch. 

4. Although proof by figures is lacking, it is probable that 
the amount of trouble has been decidedly less than it would 
have been without the use of a proper boot. 



vn. 

A FURTHER CONSIDERATION OF A MODIFIED FORM 
OF OSTEOTOMY C!OMBINED WITH OSTEOCLASIS, 
— OSTEOTOMOCLASIS. 

W. BABTON HOPKINS, U.J}., FHUADBLPHIA. 

The subject of this brief communication may best be described 
by referring to a preliminary note read before the Philadelphia 
Academy of Surgery five years ago. 

As indicated by the name suggested, osteotomodasis, the 
operation to be described consists of combining in a modified 
form both the operations of osteotomy and osteoclasis to cor- 
rect a ciure or bend of a long bone resulting from congenital 
malformation, rickets, or vicious union after fractiu^. Briefly 
stated, two operations are done, incomplete osteotomy and 
osteoclasis. At the first operation the bone is divided with 
a chisel not completely, but through more than one-half of 
its thickness at its inner curve. After the skin wound has 
healed, but before repair of the bone has sufficiently advanced 
to r^tore the original strength at the weakened point, a period 
easily included between one and three weeks, the osteoclast 
is applied, and the deformity corrected by a fracture in the 
bone at its weak point. 

In studying the action of the osteoclast some familiarly known 
principles relating to the strength of bodies and their resistance 
to force may be referred to. Letting a square beam of wood 
represent the shaft of a bone, discounting for the time the 
variations in form which modify its strength, the manner in 
which an osteoclast exerts its force would test the transverse 
strength of such a beam. The transverse strength of a beam 
is represented by two elements, its resistance to compression 
of one-third of its thickness and its resistance to extension of 
the remaining two-thirds, the line of equilibrium at which* 
compression terminates and extension begins being the neutral 

rhMc nted at the Serenteenth Aimiial Meeting of the ABSociation, Washington, 
SbC., May U-14, IMS. 



62 OSTEOTOMY WITH OSTEOCLASIS,— OSTEOTOMOCLASIS. 

axis. '^ The limit of stiffness is flexure, and the limit of strength 
or resistance is fracture." The limit of stiffness is more easily 
reached than the limit of strength. If, therefore, a transverse 
cut is made in the beam on the side to be stretched, the latter 
will be weakened relatively more than by a similar cut made 
on the side to be compressed. The side to be stretched or 
extended will be fractured, whether a cut is made or not, the 
continuity of the beam being preserved, if at all, at that por- 
tion which is only flexed, not broken. What is true of a beam 
of wood is, so far as present piu-poses are concerned, equally 
true of the shaft of a bone. Partial section, therefore, as de- 
scribed, would seem to be a rational preliminary step to osteo- 
clasis by reducing many times the force required by the latter 
and by locating accurately the point of fracture. The use of 
the osteoclast to supplement the work of the chisel, where, 
as in hospitals, this rather cumbersome apparatus is avail- 
able, is, for reasons presently to be mentioned, advantageous. 
Whether in certain cases osteotomy may be made a safer opera- 
tion by combining with it osteoclasis as a subsequent step is 
a question which can only be decided by experience. In 
children so poorly nourished and imhealthy that tramnatism 
of any kind is likely to provoke suppuration, the danger of a 
bone section cannot be ignored. It is in cases, therefore, whose 
general condition in prudent hands negatives the performance 
of osteotomy that I venture to propose the modification of 
the latter I have suggested, as for them I believe it would 
prove safer. Osteoclasis, although having fallen to a great 
extent into disuse, is especially useful for correcting trifling 
curves in tender bones in children whose parents cannot go 
to the expense and trouble of apparatus necessary for a cure 
by gradual means. Intelligently employed, it is neither haphaz- 
ard nor barbarous, and should not, in my opinion, be allowed 
to become an obsolete operation. But our subject relates 
to that class to which simple osteoclasis is inappropriate, either 
because the bone is too hard or the apex of deformity is too 
near a joint to yield to a degree of force which can without 
risk be applied: suitable cases, in other words, for osteotomy. 
Osteotomy causes a compoimd fracture, the modified method 



W. BARTON HOPKINS. 63 

a sample fracture. Osteotomy produces usually a complete 
fracture^ while by the modified method the fracture is usually 
incomplete. After osteotomy, fixation is required immediately. 
By the other method no fixation is required during the exist- 
ence of a wound. When suppuration occurs after osteotomy 
(which, however, it rarely does), it is complicated with loss of 
continuity in the bone, — ^a suppurating compound fractm^. 
Should suppuration occur after the first step in osteotomo- 
clasis, it would involve only a bone cut, not a bone section, 
and would be surgically far less serious than if accompanied 
by loss of continuity. Following the second step, after the 
skin wound has entirely healed, there is, of course, no risk of 
suppuration, as the fracture produced is a subcutaneous one. 
Osteotomy, on the other hand, requires only one etherization, 
while the modified method requires two. The osteoclast shown 
in Fig. 4 is the one which has been used in these cases. It is 
very simple, easily adjusted, and powerful, but is not particu- 
larly original. The two counter-plates and the C-shaped 
clamp can be placed at any point desired on the pair of shears, 
and retained by binding screws beneath. The apex plate is 
swivelled to the clamp screw. The pressure plates present 
concaved faces, and have flanges on their lateral borders to 
secure the necessary pads in position. It may be said of in- 
strumental osteoclasis that it possesses the great advantage 
over what may be called manual osteoclasis, in that the force 
used with it is under perfect control, ceasing instantly the 
bone yields, producing thereby usually an incomplete or green- 
stick fracture, while the force applied by manual eflFort, on 
the contrary, cannot be so controlled, but goes on with a rush 
when the resistance of the bone ceases. 

Little need be added to this note beyond the mere state- 
ment that the modified operation has been performed in most 
of the osteotomies I have done in order to demonstrate what 
advantages, if any, it had. It was done indiscriminately in 
healthy and in feeble children. I may therefore venture the 
opinion that, while osteotomy is almost invariably free from 
risk, we have in this modification a procedure occasionally 
applicable. 



vni. 

A CONSIDERATION OF THE ''ROUND SHOULDER" 
OR "STOOP SHOULDER" DEFORMITY IN CHILD- 
HOOD, WITH ESPECIAL REFERENCE TO THE 
PROPER ADJUSTMENT OF THE CLOTHING IN 
PREVENTING AND TREATING SUCH CONDI- 
TIONS. 

JOEL E. OOLDTHWATT, M.D., BOSTON, MASS. 

The frequency with which the "round shoulder" or "stoop 
shoulder" deformity is met in growing children, without other 
evidence of disease than the weakness of the posterior should^ 
muscles, and the diflBiculty so often experienced in overcom- 
ing this defect, even under careful physical supervision, must 
have impressed all who are called upon to examine children, 
and naturally leads to reflection as to the cause of the trouble 
and its obstinacy xmder treatment. 

The condition is seen more commonly with girls than with 
boys, and from three to four years of age on to puberty is the 
penod during which the condition is most frequently seen. 
It is rarely noticed in infants or during the first two or three 
years of life, and it is a matter of considerable surprise to see 
children at this period with well-formed round chests and 
well-poised shoulders gradually develop this weakness as they 
become older. 

. ^^ys the condition is usually outgrown at or before 
d S^^ ^^ P^^rty. With girls this is less often the case, 
an the weakness of the scapula muscles remains to be seen 
not mfrequently in adult life. The condition is naturally seen 
most often in poorly developed children, but it is also seen 
oftWs!? ^^^^^'^s® strong and well developed, the weakness 
preln^ ^^^P ^f muscles being the only apparent defect. 

D.C, May U-ii^ig^® Seventeenth Annual Meeting of the Aflsociation, Washington, 



JOEL E. CJOLDTH\\AIT. 65 



In considering the subject, and as the result of the exami- 
nation of a large number of children, both in the hospital clin- 




Fic;. 1. 



ics and in private practice, it has seemed to me that the chief 
factor in the etiology of this condition is the improper ad- 
justment of the clothing, especially as the condition develops 



66 KOUND SHOULDER DEFORMITY. 

as the simple clothing of infancy is discarded and the heavier 
and more complicated costume of the child is assumed. The 
opinion is strengthened by the fact that the condition so often 
corrects itself at the time of puberty, when the arrangement 
of the costume again changes, the shoulders at this period 
being depended upon less for the support. 

In studying the costume of the young growing child more 
HI detail, it will be seen that all of the heavier garments or those 
from which any drag could come, including the stocking sup- 
porters, are attached to the under-waist, and that this under- 
waist is carried entirely upon the shoulders. Of these under- 
waists there are many styles, some expensive and some very 
inexpensive, but practically all are so made that the weight 
is applied at the outer or movable portion of the shoulder, 
the position which is least capable of carrying weight. This 
is clearly shown with the resulting attitude in Fig. 1. Anatomi- 
cally, the position of the shoulder is maintained by the clavi- 
cle, with its attachments in front and by the scapula muscles 
in the back. It is evident that anything that causes pressure 
or drag upon the outer or movable part increases this muscular 
action, and that, while in moderation the muscles may respond 
to the task, if the strain be continued during all of the active 
part of the day, muscle fatigue and later permanent weakness 
must result. In this condition the shoulder must be depressed 
or lowered, but from the bony clavicular attachment in front 
and the ribs supi)orting the shoulder below when it is depressed 
it iimst come forward, and, as it is drawn forward, the posterior 
edge of the scapula is thrown into greater prominence. 

From actual measurements the drag upon the shoulders 
when the clothing is adjusted represents at least three or four 
I)ounds on each side, and, when it is realized that this is expected 
to be carried not for a f(nv minutes, but for all of the day, the 
muscle fatigue with the ultimate nmscle atrophy is not to be 
wondered at. If this be of the im{)ortance wiiich it is consid- 
ered by me, the fact that the treatment, without correcting 
this element, is tedious and often a disappointment is easily 
explained. 



JOEL E. GOLDTHWAIT. 



r>7 



In considering the various waists which are commonly used, 
not only do they apply the support at the outer portion, that 
which is the least able to carry the load, but there is also in 
many of them a strap which draws from the outside of the 
shoulder to the median line in front, the effect being to draw 





Fig. 2. 



Fhs. 3. 



the shoulder not only down, but also forward, thus making 
muscular resistance still more difficult. 

To correct the defects of the garment and to improve the 
anatomical condition, it has been my plan to apply the weight 
at the base of the neck, or the rigid part of the shoulder, where 
any amount can be borne without the shoulder being lowered. 
At the same time it has been a part of the plan to prevent the 
drag upon the front of the chest with the consequent flattening. 

The waist which has been most satisfactory is pictured in 
Figs. 2 and 3. It is made of a firm cotton material, and is 
cut high in the neck with a rather narrow back, but with a 
loose, easy front. Two straps made of double thickness of the 



68 



ROUND SHOULDER DEFORMITY. 



same cloth are sewed to the waist, and upon these the chief 
drag conies. The straps start well at the side in front, cross 
the shoulder near the base of the neck, and cross the back to 
the opposite hip. In this way the chest is left free, and what- 
ever drag there may be tends to draw the shoulder backward 




Fio. 4. 



rather than forward. The stocking straps are attached with 
the side buttons for the clothing at the side just between the 
ends of the shoulder straps, so that the drag is applied most 
favorably. The stocking straps should never be attached in 
front, as this always produces muscle strain with resulting 
faulty attitudes. 

For summer use a skeleton waist has been used, consisting 
of a wide band at the waist line for the attachment of the 
buttons, this being supported by straps placed similarly to 
the straps which are sewed to the other waist. This is pict- 
ured in Fig. 4, and the only difference in the arrangement of 



JOEL E. GOLDTHWAIT. 



69 



the straps is that a cross strap at the back near the neck is 
necessary to hold them sufficiently high upon the shoulders. 
Occasionally, when the stoop shoulder is marked, some addi- 
tional support may be necessary, and with many of the cases it 




Fig. 5. 



has been possible to accomplish the result by using a brace made 
of firm webbing one inch wide, carried as a loop around each 
shoulder, the ends crossing in the back, and being attached 
to the belt of an ordinary stocking supporter (Fig. 5). The 
attachment of the shoulder strap to the belt should be at the 
side directly over the stocking straps, and the belt should 
be worn about the hips, and not about the waist, as they are 



70 



ROUND SHOULDER DEFORMITY. 



ordinarily used. The straps should be sewed where they 
cross at the back, a and b, Fig. 5, but should not be sewed where 
they cross at c. This allows all the body movements, both 
side and forward bendings, without straining upon the straps 




Fio. 6. 



or changing the position of the belt, as is shown in Fig. 6, the 
level of the bolt not being changed in the movement. 

It is at once apparent that with such a brace the pull occa- 
sioned by the stocking supporters, which is a very appreciable 
force, tends constantly to draw the shoulders backward; and, 
while so simple a brace cannot be expected to take the place 
of the many forms of apparatus which are used to correct round 
shoulders, it has, nevertheless, been of real value in many 
cases. 



IX. 
THE ABUSE OF FLAT-FOOT SUPPORTS. 

WI8NER R. TOWNSEND, A.M., M.D. 

The treatment of flat foot by means of some form of support 
under the foot is largely due to the excellent work of many 
men in this Association, and it seems proper, therefore, that 
the members of the American Orthopedic Association should 
call the attention of the profession to the abuse of such sup- 
ports. The fact that such a question is difficult of solution, 
and that the motives prompting publicity are often purposely 
misunderstood, is no reason why we should hesitate to give 
the proper advice and urge upon medical men the necessity 
of properly examining and treating deformities or disabilities 
of the foot. 

That the treatment of this condition without consulting 
a surgeon has become very common is evidenced by the fact 
that various forms of support are to-day for sale in all the 
larger stores where footwear can be bought, and the daily, 
weekly, and monthly lay press, in addition to the medical 
journals, contain many advertisements of plates, braces, springs, 
supports, etc., warranted to cure flat feet, perfect in fit, self- 
adjustable, and easily worn in any shoe. 

The diagnosis of flat foot is, as a rule, not difficult, but that 
errors are quite common cannot be denied, and that even the 
most expert diagnosticians may at times be puzzled as to the 
true nature of a valgus deformity must also be admitted. A 
correct diagnosis is necessary before correct treatment can be 
instituted, and an error in diagnosis generally means improper 
treatment. 

The most frequent errors in diagnosis are mistaking an 
ostitis of the tarsus or ankle, a metatarsalgia or neuritis, or 
an inflammatory rheumatic condition of the parts about the 

Prenenied at the Seventeenth Annual Meeting of the Association, Washington, 
D.C., May n-14. 1903. 



72 THE ABUSE OF FLAT-FOOT SUPPORTS. 

inner side of the foot, for a flat foot. Other errors, but less 
frequent, are the appheation of flat-foot supports for pain in 
the feet due to a eavus deformity, a periostitis of the os caicis, 
and to extreme grades of malposition after Pott's fractures. 
In one instance the writer knew of, a sarcoma of the sole of 
the foot was treated for some time by braces under the idea 
that the defonnity, disability, and pain were due to a flat foot. 
Ostitis of the tarsus or ankle is not a rare affection, and the 
writer has seen many such cases treated for flat foot. The 
patient received no benefit from the support used, and in most 
instances was made nmch worse by the pressure and the trau- 
matism of locomotion. A careful inspection of the foot, an 
X-ray picture, the atrophy of the calf, the presence of reflex 
muscular spasm, are usually sufficient to render a differential 
diagnosis easy to a medical practitioner, but the symptoms 
cannot be properly interpreted by those who have no medi- 
cal knowledge, and all such cases must necessarily be treated 
badly if they simply buy supports under the idea that they 
have flat foot. In inflammatory rheumatism or neuritis 
the same is true, and many patients continue to suffer until 
proper treatment is given, and generally are made worse by 
the use of the support. 

All the other conditions referred to have been seen, and 
the effort to increase an exaggerated arch, as in cavus, is not 
at all uncommon. The proper treatment of such cases is en- 
tirely different. 

When flat foot does exist, it does not necessarily follow that 
a support nmst be applied, because there are contra-indica- 
tions for their use. Extreme spasm, extreme deformity, or 
inflammatory conditions, may be present, and the use of a sup- 
port do more harm than good. These contra-indications are 
well known to the profession, but not to those who simply 
buy supports as they would buy any article of clothing. An- 
other damage resulting from the indiscriminate use of sup- 
ports and their application to all cases, suitable and unsuit- 
able, is that many mild in type and easily cured by medical 
men are allowed to grow worse under this faulty plan of treat- 



WISNER R. T0WN8END. 73 

ing a foot diflability by those without medical knowledge. 
Patients with disability so sUght that any medical man could 
easily cure it^ if seen when the supports were applied, may 
go on and become so seriously crippled that long-continued 
treatment and even operative procedures may be necessary 
to restore the foot to tihe normsd, and perfect restoration may 
even be impossible. 

Another error of treatment, which is the one that especially 
deserves to be considered, is the application of supports that 
do not fit, that do not fulfil the indications for treatment, 
and that are so poorly constructed that even from the stand- 
point of their makers they in no sense of the word act as sup- 
ports, because they are so frail or weak they can barely retain 
the position or shape they were made, and lose all semblance 
of it a» soon as weight is put on. That supports which simply 
tend to push up a broken-down arch can never cure a flat foot 
is not disputed by medical men, but a support to hold up 
weight must be strong enough to maintain its shape under the 
weight, yet many patients are to-day wearing supports that 
do not support, and that are simply flat pieces of metal inter- 
posed between the sole of the foot and the shoe. In many 
cases the support is applied so far forward or so far back that 
it is of no assistance in preventing deformity, and more fre- 
quently tends to increase than to diminish it. Deformity 
may actually be produced and disability caused by the use 
of improper supports, and a flat foot produced where none 
existed when the use of the support was begun. 

For the patient with a flat foot, who is his own surgeon or 
whose attention is called to the condition of his foot when 
purchasing shoes, there is but one kind of treatment, — the 
application of the support sold at that store. Of necessity 
many cases must be badly treated under these conditions. 
Many forms of supports exist, and no one can successfully 
treat the condition who has but one prescription for. its cure. 
DifTerent cases require different treatment, and this is the 
most important point in the discussion. The principles are 
not understood. The valgus or abduction of the foot must 



74 THE ABUSE OF FLAT-FOOT SUPPORTS. 

be overcome, the weakened structures must be strengthened, 
the free and normal motions of the foot must be restored, 
the deformity overcome, the patient made to walk as patients 
with normal feet should walk, and the application of a support 
simply intended to push up a weakened arch can never accom- 
plish this. Temporary relief may be obtamed, but never a 
cure where a true and severe degree of flat foot exists. A proper 
support may be applied, and all its benefit lost by an improper 
shoe. Perfect reduction of deformity may be gained by the 
use of a support, and by not strengthening the muscles and 
cultivating normal movements the foot may be still further 
weakened rather than improved. A badly fitting support 
will do harm where the same support might be of great service 
if properly made. Very slight degrees of flat foot may not 
need supports, very severe degrees may need operative pro- 
cedures. Talipes valgus, whether complicated by equinus 
or calcaneus, cannot be treated in the same manner as mild 
degrees of flat foot. 

The form of support will vary, individual preferences will 
prevail, but the treatment of flat foot should be carried on by 
medical men. Supports, if used, should be correct in princi- 
ple and properly made, and the routine practice of patients 
treating themselves or being treated by ready-made supports 
sold by those with no knowledge of the true anatomical or 
pathological conditions actually present should be discouraged. 

DISCUSSION. 

Dr. BoYAL Whitman, of New York, said he heartUy agreed with the 
reader of the paper. He would like to call attention to the fact that 
little children with pigeon-toes almost always had weak feet or knock- 
knees. These children were apt to be taken to shoe stores, and have 
the shoe raised on the outer side. This symptomatic intoeing was 
often noticed by the mothers long before they noticed any more serious 
deformity. 

Dr. B. TUNSTALL Taylob, of Baltimore, said he had seen a num- 
ber of cases, on making impressions, in which there was a definite vanis. 
These children were accordingly etherized, and the contracted tissaes 
stretched or cut on the inner side. He had recently seen a case bear- 



DISCUSSION. 75 

ing on Dr. Townsend's paper, in which the patient had been made 
steadily worse by wearing a foot-plate prescribed and made by an instru- 
ment-maker. The foot was held more abducted by the plate than it 
had been without it, and was therefore more painful. 

Dr. Whitman said he had understood the last speaker to say that 
oxdinaiy pigeon-toe was more often a deformity of the foot than a symp- 
tom. He could not agree with him on this point, and he thought it was 
worthy of discussion. 

Dr. H. Augustus Wilson, of Philadelphia, said he had been yeiy much 
impressed with the amazement of the parents when told that the former 
biadng or supports were wrong. Of course, like others, he had found 
it difficult to argue with them and convince them that they had been 
wrongly persuaded. He had succeeded best in this by asking if they 
had ever heard of those about to engage in a boat-race having their arms 
splinted and staying in bed in order that they might not become tired or 
the weakness increase at the time of the race. This way of putting it 
seemed to appeal to them more easily tha)i more elaborate arguments or 
explanation. Physicians had been opposing drug-store prescribing, and 
ophthalmologists had opposed the prescribing of eyeglasses by opticians, 
yet it was very difficult to overcome these practices. 

Dr. Newton M. Shaffeb, of New York, said it had gotten to be so 
in his ci^ that, if any one had a pain in the foot, he would go to a shoe 
store or clothing store and get a flat-foot plate or some special shoe. 
Some of these plates were made of metal, while some shoes were so 
made as to produce the same effect. He knew one patient who went 
to a department store in tMs way because she had learned something 
about flat foot and shoes from the paper presented by Dr. Lovett. 

Dr. GrOLDTHWAiT said he agreed with all that had been said in the 
paper, but he thought there was a class of cases in which the patient 
was undoubtedly flat-footed, which he had been in the habit of treating 
with flat-foot plates, and in which he had been able to obtain practically 
no improvement. In such cases he had largely given up the use of 
flat-foot plates. These cases were instances of rigid or extreme valgus 
in which it might be possible under ether to efl!ect partial correction, 
but in which by all the methods of manipulation it was impossible to 
thoroughly over-correct the feet. Many such cases came to their clinic 
after having had all sorts of manipulations. Within the past few 
months they had recognized these cases as examples of club foot of the 
valgus type, and they have been treated just as they would treat a 
persLstent case of obstinate valgus. They had usually excised the 
scaphoid, thus shortening the inner side of the foot, after which the cor- 



76 THE ABUSE OF FLAT-FOOT SUPPORTS. 

rection of the positdon was easy. He was sure the blunder had been 
in depending upon foot-plates when there was a definite deformity 
requiring a surgical measure^ The class was a definite though not veiy 
large one. 

Dr. B. TUNSTALL Taylor said, replying to Dr. Whitman, he did not 
mean to imply that all cases of turning the toes in were cases of con- 
traction of the inner structures or varus deformity, but tracings of fnany 
cases showed that the angle of deflection was greater than 35^, and that 
the inner structures were the ones at fault. 



X. 

THE IMPORTANCE OF SUPPLEMENTING TENDON 
TRANSPLANTATION IN THE TREATMENT OF 
PARALYTIC TALIPES BY OTHER PROCEDURES 
DESIGNED TO ASSURE STABILITY. 

BOTAL WHITMAN, M.D., NEW YORK. 

To estimate accurately the permanent improvement derived 
from the operation of tendon transplantation for paralytic 
talipes, one should consider it apart from the procedures with 
which it is usually combined. 

These are the removal of contractions and deformity by 
tenotomy and by force, supplemented by pong-continued fixa- 
tion in an attitude of over-correction. 

Fimctional use of a part so fixed and protected is often 
followed by the unexpected development of weak muscles, 
which, with the adaptation of the tissues to the improved 
attitude, assures for a time at least a very marked improve- 
ment both in appearance and function of the foot. If one 
adds to this the negative effect of the removal of the distort- 
ing force of the transplanted muscle, it is very often appar- 
ent that the positive gain in functional ability due to the trans- 
plantation itself is of small moment. 

I am inclined to think, therefore, that those who have had 
considerable experience in the operation, and the opportu- 
nity to analyze critically the later results, will admit that tendon 
transplantation, in its original form at least, is, on the whole, 
a disappointment. 

The limitations of treatment in cases of this character are, 
of course, evident; for, as all the muscles and the normal degree 
of muscular power are necessary for perfect function, it fol- 
lows that the disability caused by paralysis will be propor- 
tional to its distribution and degree. 

Presented at the Serenteenth Annnal Meeting of the AsBociation, Washinffton. 
D.C., Hay U-14. 1906. 



78 TREATMENT OF PARALYTIC TALIPES. 

The simplest and most important function of the foot is 
weight-bearingy which is possible even when no muscular power 
is exercised. Next in importance is plantar flexion, in which 
the leverage force of the calf muscle is employed; then dorsal 
flexion to prevent toe drop; finally, adduction and abduction. 

The object of operative treatment is to adapt, as far as may 
be, the disabled part to the work it is called upon to perform. 
In this the first essential is the prevention of deformity, which 
is often more disabling than loss of power. 

It is, of course, evident that the operation of tendon trans- 
plantation, of which the object is the utilization to best ad- 
vantage of the muscular power that remains, should be most 
effective in the slighter grades of paralysis, and that it is prac- 
tically of no value when this is severe and extensive. It is 
particularly indicated in cases of paralysis of one of the an- 
terior leg muscles, with consequent lateral distortion; yet, 
even in this class, recurrence of deformity is rather the rule 
than the exception. In some instances the relapse may be 
due to insecurity at the point of attachment or to elongation 
of the overburdened graft, but the most constant cause of 
failure is the mechanical disadvantage at which the trans- 
ferred muscle must do its work. This advantage may be 
lessened by disregarding the tendon of the paralyzed muscle 
and attaching the transplanted tendon directly to the perios- 
teum at a point of selection, as advocated by Lange. To as- 
sure the security of this attachment, I have for some time 
inserted the tendon or its silk prolongation through a hole 
bored in the bone itself. 

The point to which I wish to call particular attention, how- 
ever, is the importance of reinforcing the comparatively inef- 
fective operation of tendon transplantation by proc^ures 
designed to prevent deformity and to lessen the strain upon 
the weak muscles. The centre of lateral motion of the foot, 
and consequently of lateral deformity, is the medio-tarsal 
joint; and, whenever the principal abductor or adductor of the 
dorsal flexors is lost, the remaining muscles, although possess- 
ing sufficient power to raise the foot at the same time, draw 
it to one or the other side. 



ROYAL WHITMAN. 79 

The indication for treatment is to check lateral mobility. 
Lateral motion is, of course, of value in a normal foot, but 
it is of little consequence in one weakened by paralysis, and 
it is a distinct source of weakness if it induces deformity. 

The most common and most important form of acquired 
disability is that caused by paralysis of the tibialis anticus 
muscle, whose loss is always accompanied by valgus and by 
sufficient toe drop to increase the discomfort and awkwardness. 

The operation that I reconmiend in a tjrpical case of this 
character is conducted somewhat as follows. After all re- 
striction of motion has been overcome by forcible manipula- 
tion, an incision about two inches in length is made along the 
line of the tendon of the tibialis anticus muscle, the lower end 
of which exposes the lateral aspect of the astragalo-naVicular 
articulation. This joint is opened, and the cartilage is thor- 
oughly removed from the apposing surfaces of the bones, or, 
if the valgus is extreme, a wedgenshaped section, including 
the joint of sufficient size to insiu*e slight varus, is removed. 
The extensor proprius hallucis tendon is then divided at a 
point about one inch from the toe joint, is drawn through 
a hole bored in the navicular, and is sutured to itself and to 
the periosteum at a sufficient tension to hold the foot in normal 
position. In most instances the tibialis anticus tendon is 
shortened to the same d^ree. The foot, the tendo Achillis 
having been divided if necessary, is then turned to a position 
of slight adduction and dorsal flexion, and the divided tissues 
over the jomt are sutured, with the aim of holding the de- 
nuded surfaces of the bones in close apposition. The foot is 
then fixed in a plaster of Paris bandage for three months or 
longer, the patient usmg the part in walking as soon as the 
discomfort following the operation has subsided. As a rule, 
in the cases in which supervision is exercised, no apparatus 
is required, but a brace should be used if power is lacking for 
dorsal flexion. 

It may be stated that in the treatment of children the hole 
in the bone is made by means of a curved trocar and canula. 
This latter is essential in order that the tendon may be drawn 



80 TREATMENT OF PARALYllC TALIPES. 

through without violence. It might be supposed that the 
complete removal of its tendon would be followed by the 
dropping of the great toe, but in these cases there is abnost 
always hammer-toe deformity, and the power of the accessory 
muscle (extensor brevis digitorum) ia quite sufficient to hold 
it in proper position. 

In the treatment of varus caused by paral3rsis of the peroneus 
brevis, the foot should be fixed in abduction after arthrodesis. 
In this case the hallucis tendon should be attached to the 
cuboid bone, or, if a graft is taken from the tibialis anticus, 
it is elongated sufficiently with silk to permit this attachment. 
If the varus deformity is extreme, a wedge-shaped section 
may be taken from the outer border of the foot to include the 
calcaneo-cuboid joint. 

When the calf muscle is paralyzed, and especially if the 
resulting deformity is of the calcaneo-valgus or varus type, 
I have found the most effective operation to be astragalectomy, 
with backward displacement of the foot upon the leg, removal 
of the cartilaginous surfaces of the apposing bones, trans- 
plantation of the peronei tendons to the os calcis, shortening 
the elongated tendo Achillis, being minor parts of the opera- 
tion. The removal of the astragalus and backward displace- 
ment of the foot restores symmetry, increasing the security 
of the support, and assures the patient from recurrence of 
lateral deformity. Although arthrodesis is performed, anky- 
losis is exceptional: thus the transplantation of the peronei 
tendons may utilize the slight muscular power of these lateral 
muscles to check dorsal flexion. 

I am inclined to think that a slight degree of mobility at the 
ankle joint, if it does not lead to deformity, is preferable to 
the fixation that may be attained by simple arthrodesis. It 
is true that, if a paralyzed foot is supported in proper position 
by a well-fitting plaster bandage or brace, the patient may 
walk with ease, but the same freedom is by no means assured 
when the weakened part is subjected to strain. In my own 
experience discomfort persists for a long time after the opera- 
tion, unless the foot is protected by apparatus, a discomfort 



DISCUSSION. 81 

which is unusual after astragalectomy. In this operation 
which I have ah^ady described to the Association {American 
Journal Medical Sciences, November, 1901), tendon trans- 
plantation occupies a very subordinate place; but I have men- 
tioned it in this connection because further experience has 
demonstrated its usefulness, and because it illustrates the 
principle to which I wish to call attention. That the object 
of operative treatment of paralytic disability is not perfect 
functional cure, but a restoration of ability to the degree that 
may enable the patient, in favorable cases, to finally discard 
apparatus. In this result stability is the first essential. 

DISCUSSION. 

Dr. GrOLDTHWArr said that this presentation of the subject seemed to 
him very timely. He had been very much impressed with the numer- 
ous statements that had been made about tendon transplantation, as if 
the reattachment of a tendon was expected to make a normal part of a 
deformed one. As Dr. Whitman has just said, it is one of the procedures 
that is to be used in correcting certain types of deformity resulting from 
infantile paralysis, but that it did not do away with a great many other 
supplementary measures. There could be no question but what tendon 
transplantation had its place as a surgical procedure. If the patient had 
a muscle which was deforming a foot, it could be made to do the work, to 
a slight degree, perhaps, that the paralyzed muscle had done, and im- 
proTe the patient's gait. In the favorable cases it made it possible fre- 
quently to discard a very clumsy brace and substitute a lighter one. 
Exceptionally, it was possible to discard all apparatus, but in most cases 
some apparatus was needed because a weak part was left behind. He 
was sure it was better to make the attachment to some stable base, such 
as the bone periosteally. Some of the most satisfactory cases function- 
ally that he had seen were those in which the operations had been per- 
formed upon the thigh in reattaching the sartorius, gracilis, or biceps 
muscles. Without the operation it had been necessary for the patient 
to walk with the hand holding the thigh in extension, or else make use 
of apparatus for this purpose. By the transplantation of the sartorius, 
the biceps, or the gracilis, although the part was functionally weak, 
there was frequently enough support in the muscle to steady the leg 
and aUow the patient to walk upon a level surface without any support. 
Frequently there was sufficient strength in the sartorium to allow of the 
patient's sitting and horizontally extending the leg. In a case shown in 



82 TREATMENT OF PARALYTIC TALIPES. 

Boston at a recent meeting the child wore an ordinary club-foot shoe for 
support at the ankle, and yet it was able to sit in a chair and hold the 
leg out perfectly straight with the brace applied. 

One other result in tendon transplantation had perplexed him consid- 
erably ; i.e., along the sheath of the tendon, in its previous location, a 
cicatrix occasionally forms, just as it forms between the divided ends of 
a tendon after a tenotomy. This later on organized and gave the tendon 
a double pull. This he had seen especially in connection with the trans- 
plantation of the posterior peroneal tendons, where it was difficult to 
destroy the old sheath. These tendons, therefore, later on pulled in the 
line of the old attachment as well as in the new attachment, which re- 
sulted in a diversion of a considerable portion of the power. 

Dr. H. A. Wilson said he felt personally indebted to the reader of 
the paper, especially because it would tend to remove a prevalent 
opinion among the profession that tendon transplantation was a sort of 
cure-all. Frequently he had had cases brought to him with one or two 
muscles still active, and with the hope that these muscles could be used 
to restore the original function of the part. When Nicoladoni's enthu- 
siasm reached the clinic in Vienna, much work was done in tendon 
transplantation ; but it was very quickly abandoned, probably because 
the operation had been looked upon as largely curative, and no supple- 
mentary measures or apparatus had been used. He would like to ask 
Dr. Whitman whether the method he described was original, or whether 
it had been described about a year ago by some Grerman surgeon. He 
was under the impression it was referred to last fall in the British 
Medical Journal as an original procedure. 

Dr. Whitman said that he had been interested in Dr. Groldthwait^s 
statement. Lange claimed that tissue formed around silk which had 
been used to lengthen tendons, and that in this way a cicatricial tendon 
could be formed which would do the work of the original tendon. He 
had employed the method of boring holes in bones whenever this was 
feasible. He did not know that any one else had done it except, per- 
haps, Wolff. He did not know the exact technique followed by Wolff, 
and he did not personally claim any special originality for the method. 
The operation of arthrodesis made the transplantation of the hallux 
tendon effective, whereas otherwise it would be ineffective. If one 
could prevent the recurrence of the valgus, the result would be satisfac- 
tory, otherwise it would not be. It was to the combination of procedures, 
which had not to his knowledge been especially urged before, that he 
desired to call attention. 



ABSTRACTS. 



SCOLIOSIS. 

X. An Experimental Contribution to the Study of Scoliosis. The Influence 
of the Erector Spine Muscles upon the Spinsl Column of Rabbits. 
From the laboratory of the surgical clinic, Bern. By Dr. C. Amd, 
Privatdocent and Sekundararzt of the surgical clinic. 47 illustrations. 
Archiv fur Orth,, etc., Bd. I. Heft 1 & 2. 

The author discusses the etiological theories of scoliosis at considerable 
length, showing how widely discordant they are and how important it is 
that experimental work be done to reconcile them. He then analyzes the 
experimental work of Lesser, Motta, Ribbert, and Wullstein, and describes 
the results of his own work on rabbits^ in which he studied the effect of one- 
sided weiduiefls of the backs of anmials produced by excising a portion 
of the erector spins muscle of one side in the region he desired to stuoy. 

In the first experiment (age of rabbit not stated) Amd cut out the 
erector spins on the right side between the tenth rib and the third 
lumbar vertebra in November, 1900. The rabbit died in March, 1901, — 
a period of about four months. During life a curvature developed with 
convexity to right. Post-mortem examination showed a right convex scolio- 
sis from the twelfth dorsal to the third lumbar vertebra, below this a left 
convex lumbar-sacral compensatory curve. The sacrum was 1 mm. longer 
on the left side, and the top of the sacrum was twisted 15^ dorsally on the 
left. The fifth lumbar vertebra shared in lesser degree in the twist, and 
was 3.35 mm. shorter on left side. In the fourth lumbar vertebra was found 
the banning of the right convex curve^ which reached its maximimi at the 
secondlumbar vertebra, and was recognizable in the eleventh dorsal vertebra. 
The deformities of the vertebrae showed the characteristic shortening on 
the concave side and torsion backward to the right from the fourth lumbar 
to the twelfth dorsal inclusive, the torsion in each vertebra between upper 
and lower faces varying from 6^ to 15^. 

He operated on several other rabbits, and got imiformly a scoliosis with 
convexity toward the injured side, and with greatest deformity in the region 
of operation, but with certain variations, which he considers so significant 
as to lead him to state as the conclusion from his experiments that the funda- 
mental curve is convex toward the strong side (near the rump), and that 
the convexity toward the weaker side higher up is secondary, and results 
as a compensatory curve from the efforts of the animal to walk so that the 
hind legs will follow the front ones properly. 

He calls attention to the fact that in artificial scoliosis the bones are normal 
as to growth conditions and solidity, and that in animals going on four 
legs we get inequalities of muscular puU rather than of weight pressure and 
consequent muscular effort, and therefore such experiments ao not have 
much value in the study of numan scoliosis. 

He gives a bibliography of 84 titles. — (?. W, Fitz, Boston. 

a. Orthopedic Qjrmnastics. By Mme. Nageotte Wilbouchewitch. Paris: 

C. Naud. 1903. 

In a book of over three hundred pages Mme. Wilbouchewitch describes the 

origin and treatment of faulty attitudes. After a brief statement of the 

pathological anatomy of scoliosis, she describes faulty position when at rest 



84 ABSTRACTS. 

and positions while working which cause deformity, with photographs and 
detail of each position. After this, methods of measurement of scoliosis, kinds 
of scoliosis and their treatment, are considered. Prophylactic precautions 
in school and at home are suggested. The work is too long to describe in 
detail. It is full of illustrations. — Robert SotUter, Boston, 

3. " Corrector," an apparatus for the treatment of deformities of the spine 

without a corset. By Theodor Wohrizek, Prag. 11 illustrations. 

Arckiv fur Ortk., Bd. I. Heft 1. 
This is an apparatus devised by Dr. Wohrizek for the correction and treat- 
ment of deformities of the spine, which is to be only temporarily applied 
in the office or in the school. Wohrizek does not favor the corset, as it im- 
mobilizes the muscles and interferes with the functions and development 
of the vital organs. The apparatus is described and fully illustrated m this 
article. It has for its fundamental principle a statistical method of causing 
an asymmetrical corrective pressure of the scoliotic region. He claims special 
value for it in the treatment of scoliosis, and that it may be used in schools 
with a work desk especially designed to go with it. — D, Towntend, Boston. 

4. The Correction of Spinal Curvatures. By v. Modlinsky. pp. 580. 

The author describes his method of treating Pott's disease and such sco- 
lioses as are past treatment by the simpler methods of hygiene and gym- 
nastics. He Degins by making forcible extension of the whole spine in an 
horizontal apparatus of his own device. This is maintained by the appli- 
cation of plaster, always including the head. Scoliotic cases should be pre- 
pared by mobilization and forcible massa^. The final correction is assisted 
Dy the mclusion within the plaster dressmg of suitable pressure pads. He 
requires for the complete correction of these cases from three to six months 
and from three to four applications. 

The results obtained in this way are, however, deceptive. The correction 
has been too rapidly made and at the expense of the patient's health. It 
cannot, for this reason, be maintained. It is more rational to expect success 
from portative apparatus, attempting in this way to imitate our methods in 
treating similar chronic conditions of the joints. The difficulty has lain in 
the absence of truly effective apparatus. 

This is to be constructed after the Hessine tvpe. It consists of a light 
steel and leather corset, embracing pelvis and thorax to the middle of the 
scapulae. Fixation is accomplish^ by means of slots and screws. At- 
tached to the pelvic part, in the region of the trochanters, are two lateral 
uprights of steel, supporting rectangular frames, whose function it is to 
transfer the weight of the head to the lower extremities without the aid 
of lumbar and thoracic segments. Transverse bars attached to these frames 
carry the anterior and posterior pressure pads, respectively. The head 
piece is a leather ''Minerva,'' resting upon tne upper horizontal bar of the 
rectangle. 

The illustrations of the apparatus are satisfactory. — A, H, Freiberg, Cin- 
cinnaJLi, 

5. Differences in the Scolioses of Male and Female Individuals. ZeUschr, 

fur Orth. Chir., xi. 298. 
A. Sutter finds that the relation of scoliotic male patients in sanatoriums 
to female patients is as 1 : .7: in school statistics, however, it is as 1:1. Sco- 
liosis, therefore, is as frequent in one sex as in the other. It occurs some- 
what earlier in the life of females than of males. The greater number of 
the vertebral distortions are convex toward the left, but there are more 
distortions to the left in males than in females. In boys it is usually the 
upper portions of the spine which are deformed: in girls, the lower are 
deiormed almost as often as the upper. The deformities are more marked 
in boys than in girls, [b. l.] — H. A. WiUon, Am. Med, 



ABSTRACTS. 85 

6. Congenital Scoliosis. Zeitschr. fur Orth Chir., 1903, xi. 411. 

H. Maass reports such a case in an infant three months old. The scoliosis 
iraa convex toward the left side; its point of greatest prominence was at 
the height of the ninth thoracic vertebra; the deviation amounted to 3 cm.; 
the cosUJ deformity to 2 cm. The remainder of the skeleton seemed perfectly 
normal. He sees the cause in an anomalous intraruterine position. The 
treatment which produced an excellent result consisted of a plaster dress- 
ing and pressure massage of the deformity, [b. u}—H. A . Wilson, Am. Med. 

7. Anatomical and Clinical Value of Orthopedic Corsets. By Dr. Wil- 

hehn Becker, Bremen. Archiv fur Orth., Bd. I. Heft 1, 1903. 
The value of a spinal sup{)ort depends upon the consideration of the spine 
from an anatomical mechanical standpoint. So considered, we must regard 
the vertebral column as firmly fixed oelow by the pelvic ^prdle and freelv 
movable in the part above. In relieving the spine of the weight of the head, 
the head support should not grasp uncter the chin, but by tne occiput ana 
forehead. The arm-pits cannot be considered support pomts for the spine, 
for the shoulder-girdle is only loosely attached. It is further to be remembered 
that the spinal column is onlv approachable from behind. In Pott's disease 
it is important that the appliance fits snugly over the hips, for on that de- 
pends our ability to get pressure against the knuckle. If die corset is merely 
for support, it would nave to reach no higher than the knuckle, and the 
higher that is, the easier to set support; but a packet which reacnes above 
the knuckle prevents latertQ deviation. Lumbar kyphosis is difiicult to 
treat, because the distance to the knuckle is so short, ana because the normal 
lordosis is obliterated or reversed. There are four things to be f;ained by 
corsets: (1) fixation* (2) support; (3) extension; and (4) correction. Fix- 
ation corsets are to be worn day and night; and, if they are to be removed, 
it is weU to do so under suspension. Imation implied support, but support 
without fixation may be indicated in cases of long standing. Both fixation 
and support can only work on small parts of the column. Extension has 
its effect on the whole. One grasps both ends; namely, pelvis and head, 
not the arm-pits. Extension may be used to correct; but the only other 
way to get correction is by pressure upon the ribs, which are bound to inter- 
vene between jacket and spine. There are four eroups of chest deformitv: 
nervous, rachitic, spondylitic, and habitual, which have their special indi- 
cations for mechanical support. The Wullstein corsets are of great value 
because that part of the treatment is only one link in a therapeutic chain, 
being preceded or accompanied by other measures. — Henry Feisa, Cleveland. 

& School and Spinal Curvatures. By Schulthess. Voss: Hamburg. 1902. 

Schulthess denies that the school is the only or even the principal cause 
of lateral curvature and round shoulders, on the ground that a great many 
of these cases are seen well advanced before the school age. Institutional ex- 
perience does not compel the belief in a special form of school scoliosis. 
The frequent occurrence of left lumbar convex and right dorsal convex forms 
is explainable in part by the normal mechanics of the spine and by certain 
pathological conditions of the vertebne. Right-handedness and the dis- 
placement of the pelvis toward the left, as well as the incurvation of the 
spine toward the right associated with it, flattening of the bodies by the 
aorta, and the slight inclination of the spine toward the left caused by this, 
all influence the form of the curvature. All school investigations show about 
an equal frequency in boys and girls (boys, 23 per cent. ; girls, 26.7 per cent., 
in Lausanne). As a^ advances, the frequency m girls increases almost three- 
fold, in boys not quite twofold. On the average, one fijids somewhat more 
than double the number in the oldest children, found in the classes corre- 
eponding to the ninth year. This indicates as much the progress of old sco- 
hoses as the formation of new. 

56 per cent, of all scolioses are total. The lumbar follow with 20, dorsal 



86 ABSTRACTS. 

12.7, and combined with 8.5 per cent. Increase of total scolioses forms 
the main contingent in the added frequenc}'^ of scolioses. In addition, the 
lumbar ciurves of girls show a decided increment. 

The result of tne Lausanne investigation has been to show the increase 
of total scoliosis and the lumbar curves in girls. Schulthess says that the 
position in writing gives the spine of a child naturally disposed to 3rield towazxl 
the left an opportunity to assume this position often and to maintain it 
for long periods. He therefore regards sinistro convex total scoliosis and 
the lumbar curves of girls as forms especially favored by school occupa- 
tions, and therefore justifiably called ''school scoliosis'' in a certain nmnber 
of individuals. Curves whose beginning were indicated before school life 
are accentuated. Sitting, lack of exercise, etc., favor the further develop- 
ment of the abnormal growth already begun; but the school is not entitled 
to all of the blame. 

In prophylaxis he recommends shortening hours, insists upon hourly pauses, 
regular gymnastic exercises, proper illumination, suitable furnittire, perpen- 
dicular writing, and frequent examination of pupils. Decidedly deformed 
children shoula be put in special classes. — ^46^/. Zeitsckr. fur Orih. Chir., xi. 3. 

9. The Correction of Severe Scoliosis and Kyphosis. BySchanz. Wien, 

klin. Rundschau, 1902, No. 61. 
In proper cases this is the most successful method of treating severe cases. 
Bv forcible correction, however, we can accomplish only the straightening. 
The process itself can only be terminated by restoring the balance between 
the functional potency of the spine and the function^ demands made upon 
it. The redressment is made in his extension frame by applying a weU- 
padded plaster dressing from trochanters to head under powerful extension. 
During the setting further correction is made manualty. After three to 
four days the procedure is repeated, and acain after similar inter\''als, untU 
no further improvement can be obtained. He has noticed as much increase 
of body lengtn as 18 cm. After one and one-half months this dressing is 
replaced by a hardened leather and drilling corset with head support. Dur- 
ing the night a posture bed is used. Ener^tic treatment by gymnastics 
and massage is now given. The treatment is not concluded until the pa- 
tient holds himself in the corrected position. Exercises and the corset are 
continued for several years longer. — Abst, ZeUachr, fiir Ortk. Chir,, xi. 3. 

10. Clinical Observations on Backache. Robert W. Lovett. New York 

Medical Journal^ May 30, 1903. 
From an orthopedic standpoint certain well-defined types of backache 
present themselves which are divided roughly into two raroups, those due 
to causes existing in the spine itself and those due to external causes. Among 
the first is faulty spinal attitude, in which the extra strain is borne by certain 
ligaments not calculated for them. In round shouldered, lax-spined young 
women, pain is not infrequent, and is familiar under the name of irritable 
or neurasthenic spine. In lateral deviation of the spine, when due to a shorter 
leg on one side, pain is not uncommon, and is often situated in one or the 
other of the sacro-iliac joints, or in the loin or around the scapula. The pain 
is on the convex side of the curve rather than on the compressed side. The 
correction of the shortened leg by a thick sole will in many cases do away 
with the backache. The cases due to injury or trauma include sprains of 
the back, which are often serious, far more so in their symptoms than would 
be suggested by the anatomic conditions. Instead of being put to rest 
like an injured ankle, it is the rule that the parts are kept in action, and the 
treatment is therefore embarrassed. In chronic or acute /sprain absolute 
rest and fixation are necessary, or their restricted use. There is also a per- 
sistent backache without obvious cause. Three conditions of the foot are 
mentioned, such as fiat foot, which is not common in private practice; pro- 
nated foot, which is more common, the weight of the body being transmitted 



ABSTRACTS. 87 

diagonally through the arch instead of straight down, and pain and irrita- 
bility result. This is most commonly called flat foot, but it outnumbers the 
cases of real flat foot many times over. Another condition is what is called 
contracted foot, which is very little known and but imperfectly understood. 
It is characterized by shortness of the muscles of the oack of the calf, and 
their stretching is necessary in the treatment. Backache is a common accom- 
paniment. The pain from these three conditions is generally in the small 
of the back, and is aggravated by stooping or standing. It also results from 
walking. The real flat foot and pronated foot are easily treated by foot plates, 
and the backache disappears if this is the cause. In case of contracted foot, 
stretching of the calf muscle is necessary, and the under side of the foot 
must be supported by a pad or a short steel plate. The arch of the foot must 
be correctly supported. — Abat. in Jovr. Am, Med. Aw'n. 



SPINE. 

zi. Tillman's ^'Qenesis and Treatment of Spondj^tic Paralysis." Van 
Langenbeck'B Arcktv, vol. 69, Nos. 1 & 2. 

Spondylitic paralysis is comparatively rarely brought on b^^ direct bone 
pressure. This happens only (1) by bone edges when the spinal cord has 
been fixed by dural adhesions; (2) by sequestrse; (3) by callus, this usually 
in the older, more nearly restored cases. Paralysis may come on also in 
consequence of peridural connective tissue increase. During the course of 
spondylitis itseu, paralysis is most frequently caused by exudation, ab- 
scesses, and caseiform products of decay. Later on, in the natural course of 
events, by peripachy-meningitic granulations. Much depends upon the 
pressure to which an epidural exudate has been subjected. A lessening 
of the pressure is followed by a yielding of the paralysis. It is for this rea- 
son that often S3nichronouflly with the formation of a superficial abscess 
there comes a eeneral improvement. Pressure causes an oedema within 
the spinal cord, which undergoes in consequence trophical disturbances. 
Duration of the process is less important than intensity of pressure. 
Losses of nerve substance can never be made up. 

The treatment is a bloodless orthopedic one. Extension and redressing 
apparatus for rest and support should be considered. Even after the paraf 
ysis has begun to improve, the vertebral column should be kept in fixation 
as long as possible. ''Kyphosis" not yet fixed, and not too old, can l>e 
redressed by decrees. Of course, in the perfectly fixed and very old cases, 
this cannot be done. 

Operations. — ^Two methods: — 

(1) An opening into the vertebral bodies from the side and a permanent 
drainage. The best method of performing this is the costo-transversectomy 
of M^iuurd. This will be applicable in the not too old cases of tuberculosis 
of the vertebral bodies. 

(2) Laminectomy, especially in cases of caries of the vertebral arches, 
and as a late operation m the older, nearly cured cases, in which granula- 
tions, callus, sequestra, and bone edges have been the causative agents. 

Every operative procedure must always be followed by long orthopedic 
after treatment.— -A 6«/. Archiv fur Orth., Bd. I. Heft 2. 

la. On the Casuistry of the " Bechteren " Stiffness of the Vertebrae. Disser- 
tation of inauguration (F. D.), Jena, 1902. By H. Vollheim. 
A discussion of one case of stiffness of the vertebral column limited to the 
lumbar rc^on. The case therefore was very like that described in No. 1 of 
the Archives referates, the essential difference being that in one an infec- 
tious (influenza) origin was supposed, while the other case followed pure 
traumatism. The author sifts tne significant cases, but believes it impossi- 



88 ABSTRACTS. 

ble to completely separate the Bechteren and the Strumpell-Marie t3rpe8. — 
Abat. Archtv fur Orth., Bd. I. Heft 2. 

13. The Presentation of Diseases of the Spine by Roentgen Rays. By P. 

Sordeck. Hamburg: Eppendorf. Archiv fur Orih. 
Dr. Sordeck discusses the difficulty of examination of the spine, and shows 
the value of the Roentgen rays in determining the presence of disease and its 
site. He claims the best success is obtained in the cervical region, in spite 
of the small bodies and processes of the vertebne, then with the lumbar, 
and lastly with the dorsal region, which is most difficult, owing to its close 
proximity to heart and liver. In order to obtain success, the observer 
must make a systematic study of each vertebra, and must take manv 
plates of each case. He also describes the technique to be observed. 
Then follows a description of the various regions of the normal spine and 
their peculiarities, as shown by the Roentgen rays, and the patnological 
chan^ of the spine and vertebrs in scoliosis, fractures, luxation, and 
luxation fractures, tuberculosis, caries, cold abscess, nia%nant tumors, 
ankylosing spondylitis, and congenital deformities (spma bifida, etc.). He 
gives a series of clinical cases with analyses of the radiographs of each. The 
article is accompanied by 19 Roentgen pictures. — D. Towniend, Boston. 

14. Localised Traumatic Inflammation of the Vertebral Column. By Bett- 

mann, Leipzig. Archiv fur Orth., Bd. I. Heft 2, 1903. 
The article is a discussion of a case of injury to the spine to illustrate the 
far-reaching effects of what is often mistakenly called a sprain or stretching. 
The medico-legal aspect is considered. Objective signs may be entirely 
lacking. In the case in point the patient complaint for many years of 
pain and disabilitv, and finally deformity came on. There was marked 
stiffening and loraosis in the lumbar re^on. The course and pathology of 
such cases is given, and the condition designated as traumaticalty ankyiosed 
spine. — Henry FeisSf Cleveland, 



BONES AND JOINTS. 

15. The Development of the Radiograph. By G. C. Johnson. Journal of 
Advanced Therapeutics, April, 1903, p. 224. 
Johnson gives some practical hints on the proper development of an X-rav 
plate. He emphasizes the necessity of becoming thoroughlv familiar with 
one kind of developer, as a great deal of time is wasted by the average man 
in experimenting with plates and developers. By trying all that there are 
on the market, one may know much about developers and very little about 
development. By constantly using a developer 01 known value, one learns 
how to modify it to suit the various exposures. As a rule, it is best to use 
the developing formuke that are found in all boxes of plates. It must be 
borne in mind that an X-ray plate requires developing to a much greater 
density than for any other purpose. For an over or under exposed plate 
the best remedy is to throw it away, and make a proper exposure. An 
under-exposed plate is never satisfactory. The secret of success is to leam 
the capacity of your machine under varying conditions and to judge the 
current passing tnrough the tube, and govern the length of exposure by the 
Quantity and penetration of the rays emitted during the exposure. Bslance 
these against the size, weight, and muscular development of the patient. 
In this way only can a correct exposure be formulated. The successf\il 
radiographers are those who use one brand of plate, one developer, a given 
type of apparatus, and a tube with whose every mood they are familiar. — 
L,A, Weigel, Rochester, 



ABSTRACTS. 89 

z6. The Roentgen ftayn: In Differentimdng between Osteomyelitis, Osseous 
Cyst, Osteossrcoma, and Other Osseous Lesions, with Skiagrsphic 
Demonstrations. By Beck. Jour, Am, Med. As8\ vol. 28, No. 1, 
1902. 
Beck presents a number of skiagraphs showing what the Roentgen rays 
will do m differentiating between osteomyelitis, osseous cyst, osteosarcoma, 
and other osseous lesions. He shows that the X-rays are of value in making 
an early diagnosis in cases of osteomyelitis, and that it will demonstrate every 
focus of the disease. Abscesses may be so weU outlined that the technical 
steps of the operation may be definitely traced in advance. If but one focus 
shows, no other r^on of the bone need be attacked. The size and shape of 
sequestra can easuy be made out and every position defined, and many 
times the rays will show one which it is impossible to feel with a probe. In 
arthritis the contours appear indented and in places veiled. Deposits are 
recognizable as light shadows, as they consist of translucent muric acid 
salts. In all tubercular lesions of the bones and joints the rays give definite 
information as to the seat and exact extent of the tubercular areas. Peri- 
osteal sarcomata are characterized by spiculated trd^uls radiating from 
the surface. The soft variety shows absence of osseous tissue, except small 
fragments. A skiagraph of an osteosarcoma proper shows more osseous 
tissue than the former varietur, but its outlines are very irregular. Beck 
considers the skiagraph expression of syphilis as characteristic. — L, A. Weigel, 
Rochester, 

If. A New Contribution to the Treatment of Tuberculosis of Bones and 
Joints of Children after the Lannelongue Method. By M. Motta. 
Archiv fur Orth,, No. 3, 1902. 

Motta has for ten years foUowed the Lannelongue method with g^ood 
and at times splendid results. He describes the technique. The injectbns 
should not be xnade directly into the affected part, but onlv into the imme- 
diate surrounding tissues. The periosteum is to be injectea in case of bones 
and joints, and the periglandular issue in case of adenitis. 

Dmering from Lannelongue^ he at once applies a compression dressing, 
and prefers to repeat the injection, which for the first time is not very 
stronjg. He uses a 10 per cent, solution, and carefully avoids letting the 
solution come in contact with the skin, in order to guard aeainst an easily 
occurring necrosis. The injection, therefore, should always be made under- 
neath the fascia, and^ if rather superficial, the needle should be introduced 
in an oblique direction. The compression dressing makes the operation 
relatively painless, often not requiring narcotization. 

Out of 24 cases of Joints, he cured 14 with almost perfect mobility, 3 with 
90*', 3 with 40 to 45 , and -4 with ankylosis. He states that the injections 
should not follow each other too quickly. The reports of the diseases he 
has cured are given in full, and include other affections. He warmly recom- 
mends the method to physicians, considering the fact that the cicatricial 
tissue can be differentiated from the affected tissue, and thereby later opera- 
tions, if in certain cases they should become necessary, are made easier. — 
Abst. Archiv jur Orth., Bd. I. Heft 2. 

z8. The Spontaneous Correction of Bone Deformities. By Port. Mun, 
Med. Woch., 48, 1902. 
A case of severe rachitic curvature of the leg is reported, in which in the 
course of time a considerable amount of spontaneous correction occurred. 
According to the radiogram, the straightening took place as the result of 
a compensating deviation of the bone's long axis at the epiphyseal line, 
product by tmequal growth at this place and by the compensatory unequal 
activity of the periosteimi. Port considers this observation as valuable 
evidence against the far-fetched conclusions which have been drawn from 
Wolff's observations on the transformation of bone, correct though they 



90 ABSTRACTS. 

be within certain limits. This pertains especially to the changes of the form 
of the bones in response to changes in function in adult individuals. He 
believes that these transformations can, for physiological reasons, take place 
only in children, and even in these are restricted to such bone particles as 
are destined by natural growth to disappear. In their place properly 
arranged trabeculse are formed. In inflammatory conditions and fractures 
only can the bone of the adult become again active in this way, the perios- 
teum being put back into a formative condition. — Abst, ZeiUchr. fur Orih, 
Chir., xi. 3. 

19. Osteomyelitis Albuminosa. Dissertation, Freiburg, 1903. By Sinz. 
Report and analysis of a case. The peculiar albuminous fluid is the onlv 

distinguishing characteristic feature of the disease, and the only one which 
serves to differentiate it from suppurative osteomyelitis as regards etiology, 
symptomatology, or, for that matter, pathological anatomy. He regards 
it simply as an anomalv in the course of acute infectious osteomyelitis, whose 
cause 18 as yet entirely liypothetical. — Abst. Zeitschr. fUr Orth. Cnir., xi. 3 

20. Osteogenesis Imperfecta. ByHarbitz. Norsk. Mag, F, Loffevidenskdben, 

A.63. N. I, 5L., 1902. 
Collection of twenty-one cases from the literature with report of one orig- 
inal. Radiogram. The principal characteristics of the condition are given 
as shortness of the extremities with well-developed head and trunk. The 
cranial base is normally developed, but with brittle and osteoporotic bone 
nuclei. No premature synostosis. Incomplete development of the bone 
centres of head and face. Imperfect ossification especially marked in the 
long bones. These are extremely slender, thus leading to numerous fractures. 
These may be multiple in the same bone, and may occur ante- or post-partum. 
Microscopic examination shows a proliferation zone that is of proper form, 
but too small. The various bone thickenings are callus formations after 
fracture, and not swellings of rachitic or luetic character. The cause of the 
condition is entirely unknown. Chondrodystrophy and osteogenesis imper- 
fecta are entirely distinct and, to a degree^ opposite conditions. Osteogen- 
esis imperfecta is preferred to achondroplasia as a name, because the French 
have been confusing the two forms imder this title. — Abst. Zeitschr. fur Orth, 
Chir., xi. 3. 

ai. A Case of Osteogenesis Imperfecta. Dissertation, Giessen, 1902. By 
Helwig. 
Late investigation has shown that the so-called foetal rachitis has noth- 
ing in common with true rachitis, and that it is, in fact, not to be regarded 
as an entity at all. Cases formerly described as fcetal rachitis should be 
classified either as chondrodystrophy or as osteogenesis imperfecta. The 
latter consists of an interference with bone formation, while the former is 
caused by imperfect cartilage growth and a premature cessation of endo- 
chondral ossification. A case is reported with A-ray and microscopic exam- 
ination. — Abst. Zeitschr. fur Orth. Chir,, xi. 3. 

aa. Trauma as Cause of "Locus Minoris Resistentie" in Bones and 
Joints. Dissertation, Kiel, 1902. By Prahl. 

The author attempts to show that in the production of the infectious dis- 
eases of bones and joints the presence in the body of the infectious material 
is not sufficient to account for the localization of the disease, but that there 
is necessarily some predisposing circumstance to which the inflammatory 
process owes its inception. 

A case is presented which is believed to show the infection of a focus 
of diminished resisting power as the result of trauma through the medium 
of the circulation. This was afterward found to be a piece of bone which 
was torn loose. — Abst. Zeitschr. fur Orth. Chir., xi. 3. 



ABSTRACTS. 91 

23. Lesions of the Tibial Tubercle occurring during Adolescence. By 

Robert B. Osgood, Boston. B. M. & S. Jour,, vol. cxlviii., No. 5. 

The adolescent tibial tubercle, from its situation and mode of develop- 
ment, is susceptible to injuries, especially in athletic subjects. These lesions 
are usually caused by a violent contraction of the quadriceps extensor. 

Fracture and complete avulsion of the tubercle are rare, cause loss of 
function, and are easily diagnosed, usually clinically and always by means 
of X-ray. 

Avulsions of a small portion and partial separation of the tubercle are more 
common. They do not cause complete loss of function, but without treat- 
ment long-contmued serious annoyance. The diagnosis should be made by 
a combination of the clinical and X-ray pictures; and, before the latter 
are accepted as evidence, both knees should be skiagraphed, and accurate 
technique observed. 

24. Avulsion of the Tibial Tubercle. Bv Francis D. Donoghue. B, M. 
(fc S, Jour., June 11, 1903. 

The cases previously reported have been those of active, athletic boys 
between thirteen and sixteen. The author's case is that of a girl of thirteen, 
likewise muscular and athletic. While vaulting over a horse in a ^ymnar 
slum, she fell, striking the cushion with her knee. There followed swellmg and 
pain, especially noticeable on attempting to kneel. After five weeks she 
came under the writer's observation. There was swelling, stiffness, and some 
pain, especially in the region of the tibial tubercle. The patelLee were of 
the same elevation. The Roentgen rays showed plainly the true condition, — 
avulsion of the tibial tubercle. Under treatment by strapping the leg became 
almost perfect functionally. — Abat. in Am, Medicine, 

35. Contribution to the Knowledge of Acute Bone Atrophy. By A. Ex* 
ner. Fortschritte auf dem GMete der Roentgenstrahlen, Bd. \'I. Heft 1. 
So-called acute bone atrophy may take place in fractures, acute inflamma- 
tions, gonorrhoea, lues, and numerous other diseases. There is a thinning of 
the cortex, and at the same time the spon^ portion becomes wider meshed. 
The muscles do not necessarily atrophy with the bone atrophy. It may be 
very marked, even if the primary disease is not severe. Probablv the cause 
is disturbance in the circulation. That property of the bone wnich entails 
the building up of new trabecule, according to Wolff's law, is disturbed. 
Physical experiments show a loss in the weight: chemicaUy, there is no gross 
change in the composition. — Abst, Archiv fur Orth,, Bd. I. Heft 1. 

a6. Acute Bone Atrophy following Inflammations and Injuries of the Ex- 
tremities and its Clinical Appearance. By P. Sudeck. Fortachr. a. d. 
Oeb. d. Roentgenatrahlen, Hamb., 1902, v. 277. 
Acute phlegmons of the joints frequently result in long-continued func- 
tional disturbances, especially in the hands; and this may continue for months. 
In many cases complete restoration does not take place, and stiffness of the 
fingers and wrist is more or less permanent. In these cases the phlegmonous 
process is not in the fingers themselves, but localized in the wrist jomt; and 
the change in the fingers is secondary. The condition is not due to pro- 
longed immobilization, as there is a marked change in the bone structure 
itself, which may be accuratelv demonstrated by the Roentgen rays. Su- 
deck finds these changes in tne bone very frequently after inflammatory 
processes of the soft parts. Even where there has been no involvement of the 
joints and tendon sheaths or suppuration of the finger joints, the character- 
istic bone changes are seldom absent. He gives the history of a series of 
cases in which the characteristic bone atrophy could be demonstrated, and 
included fractures into the joints, — sprains, contusions, crushing of joints, 
injury of soft parts, nerve injuries, and herpes zoster with neuritis. A review 



92 ABSTRACTS. 

of the cases shows that after traumatisms of every kind, as well as after 
prolonged inflammation (acute inflammation of large and small joints, osteo- 
myelitis, tenoBsmovitis, and phlegmon of soft parts), a resorption of bone, 
demonstrable by the X-ray, may be shown. Nerve injuries may also be a 
factor. The injuries are, as a rule, not severe. It must be admitted that 
joint affections are more apt to predispose to bone atrophy than fractures, 
and that this atrophy occurs more frequently after inflammations than from 
simple traumatism. In acute inflammations of the larger joints, at least of 
the wrist, an acute atrophy of the whole hand skeleton is the rule: and this 
also occurs quite frequently after injuries. The disappearance of tne normal 
bone structure is ve^^ marked, and shows in a surprisingly short time after 
the traumatism. The shortest time observed was four and a half weeks, 
and after eieht or ten weeks it may reach a high degree. It thus differs 
from the wdl-known forms of bone atrophy due to senility and non-use. 
In the X-ray picture this bone atrophy may be observed in various forms. 
In the earlier stages there is an irregular spotted condition of the bone shadow. 
In the hand this spotted condition is first noticed in the spon^ substance, 
then at the base oi the phalanges and metacarpals, and finally m the carpal 
bones. At times the bone appears to be perforated in roots. The compact 
layer of bone is only affected at a later period. This condition may disappear 
as rapidly as it began, so that after some weeks nothing pathological can 
be detected. With this restoration of the normal, the functional disturbances 
also disappear, if the disease has not existed too long. 

When tne atrophy has existed for a long time, the X-ray plate shows the 
chronic form. Tne structure of the bone is still visible, but aU of the lamellm 
are much more delicate and thinner than normal: the bones impear trans- 
lucent. The practised eye at once recognizes the significance of this patho- 
logical condition. In the soft parts, vasomotor disturbances are observed, 
and consist of cyanosis, with a subjective and objective coldness of the skin, 
an oedema. 

The dia^osis is based upon the skiagraphic demonstration of the bone 
atrophy, sudeck's conclusions are that he has been able to prove that, 
after inflammations and injuries of the extremities, in addition to muscular 
atrophy and trophic disturbances of the skin, an acute bone atroph^r may 
also occur, which, in the light of our present knowledge, must be considered 
as a trophic neurosis, and that, furthermore, this bone atrophy may produce 
very marked and persistent disturbances of function. The disturbance of 
function is only indirectly connected with the original trouble, so that under 
certain circmnstances the muscle and bone atrophy ma^ acquire the charac- 
teristics of an independent disease. Furthermore, it is important, not 
only for diagnosis or differential diagnosis, but also for treatment, to give 

§ articular attention to the above-described X-ray findings. It is frequently 
esirable to make X-ray plates of both the affected and unaffected extrem- 
ity, to appreciate, by comparison, the character of the bone changes. — 
L. A. Wevgelj Rochester, 

27. On Habitual Luxation. By Dr. Walter Wendel, Marburg. Archiv fur 
Orth,, Bd. I. Heft 1. 
Wendel considers the etiology of habitual luxation as given by different 
authors— Joessel, Roser, Franke, and others — from autopsies and operations. 
He discusses several cases of shoulder luxation that were observed in the 
Marburg clinic. He describes Heusner's operation of deepening the sigmoid 
fossa, also the operation of Bloch for habitual luxation of the elbow, and de- 
scribes three cases operated in the Marburg clinic. He discusses the etiology 
of the condition, the changes in the bone due to disease of cord, such as tabes 
and syringomvelia. He divides the cases into traumatic and pathological, 
and regards the traumatic as operable, while the pathological ones are dis- 
ease symptoms, and only rarely can be operated. Voluntary luxation is 
a curiosity, while the habitual is a disease. The article has 3 cuts and a bib- 
liography of 39 titles. — D. Tatcnsend, Boston, 



ABSTRACTS. 93 



CONGENITAL DISLOCATION OF THE HIP. 

aS. Results of Bloodless Reduction of Congenital Hip. By M. E. Kinnis- 
Bon. Revue d'Orthapedie, May, 1903. 

When Lorenz first brought forward the bloodless reduction of congenital 
hip. he considered it a radical operation for cure of the deformity, not a 
paliiative form of treatment. 

The following year, before the Imperial Medical Society of Vienna, he was 
obliged to acknowledge that his first statements claimed too much, the 
X-ray showinj^ in masxyr cases that there was a secondary forward ana up- 
ward dislocation following reposition. 

In 1899 Lorens made a statement of his results. In 22 cases reposition 
was impossible. In 15 cases there followed backward dislocation. In study- 
ing from the X-ray 135 of his early cases, Lorenz found 56 doubtful or in- 
complete results, and 79 satisfactory cases from an anatomical point of 
view. 

Hoffa believes that the bloodless method rarely gives permanent reduc- 
tion. Often, however, there is improvement by this metnod of treatment, 
although the result is not a complete reduction. The head of the femur 
finding a firm point of pressure against the pelvis, a good functional result 
is obtained. 

Peterson published the results of Schede at the Bonn clinic, and concludes 
that nothing is rarer than a complete reposition. In 161 cases, 70 being 
double, there were but 8 satisfactory reductions among the single cases, 
and but two amons the double congenital dislocations. As a rule, a trans- 
position is the result. 

Kimunel, of Hamburg, obtained eood functional results by transposition; 
but otherwise, in 66 congenital dislocations on 50 patients, reposition was 
obtained in but 11 cases. 

In 1900 Broca reported but two real reductions, while R^dard reported 
12 in 32 cases. 

Joachimsthal obtained 17 good results in 23 cases. 

Burghard, however, obtained but one positive reduction in 20 cases. 

Nov6 Josseraud, of Lyons, reports 25 reductions, 37 transpositions, 2 
fractures, 3 relapses, and 2 immovable heads. 

Finally, Miiller, of Stuttgart, in 40 single cases obtained 28 cures, — i.e., 
70 per cent.. — and five complete cures in 21 double cases. 

The absolute value of the bloodless treatment is not as }ret statistically 
fixed^ and Kirmisson urffes that reports of results be made in order to de- 
termme the absolute value of bloodless reposition. In his service at the 
Trousseau Hospital since 1898 (i.e., in the last five years), of 27 unilateral 
cases, 10 were either impossible or for some reason other treatment was 
tried, so that 17 cases were operated by the bloodless method, with the fol- 
lowing results: 5, no shortening; 2, 1 cm. shortening; 6, with 1 cm. shorten- 
ing; tne others from 2 to 4 cm. shortening. Functional results are good 
in the majority of cases. Of 27 bilateral 21 were treated: 3, excellent results; 
11, good results: only 3 relapses of one side, and but 1 relapse of both sides. 
There is a detail of cases and of operative procedure. 

Kirmisson favors the selection of treatment for each case in congenital 
traumatic or pathological luxation, choosing the least violent that the case 
allows rather than to succeed by force at the risk of doing much harm. — 
Robert SotUter, Boston. 

29. Present Status of Congenital Dislocation of Hip. By V. P. Gibney. 
Am, Med., May 30, 1903. 

Conclusions: — 

1. Do not rest content in a case of hip lameness in a young child until 
you have made a thofough examination and obtained a full history. 



94 ABSTRACTS. 

2. Diagnosis being established, aim to get a reduction before the sixth 
or seventh year. It is fatal to postpone operation. 

3. In cases beyond the age limit, ascertain the exact position of the head, 
its shape, and relations by an X-ray. 

4. Do not make long attempts at reduction in patients over ten years. 

5. Bear in mind the dangers which Lorenz himself has pointed* out: too 
extensive laceration of soft parts; paralysis, which may or may not yield 
in time to treatment; fracture of the femur or of the pelvic bone; the rup- 
ture of arteries, sometimes the femoral. — R. Soutter, Boston. 

30. Subluzations in Congenital Hip Dislocations. By Walther. Muen. Med 

Woch., 1903, No. 14. 
Reports nine cases of incomplete congenital luxations with tracings of 
radioj^ams. Emphasizes Lange's advice to make radiograms in external 
rotation as well as internal rotation of the thieh. In this way one may 
avoid overlooking some cases of subluxation. Antagonizes Lorenz's advice 
not to attempt the reduction until children are of cleanly habit, as by so 
doing the attempts at walking may convert some subluxations into com- 
plete luxations, making conditions more difficult. — Abst. Zeitschr. fur Orth. 
Chir., xi. 3. 

31. Curing Congenital Hip Joint Luxations by Bloodless Reposition and the 

Anatomical Procedures. By E. Mu'ller, Stuttgart. 
a. Left hip of a girl aged four years, replaced successfully two years be- 
fore. The healing was a perfect one as regards function. The muscles 
showed perfectly regular proportions. The joint itself was not to be dis- 
tinguished from a normal jomt. The socket is regular and even smooth, 
covering about two-fifths of a circle. The roof consists almost entirely of 
cartilage, the head being closely opposed. The neck appears somewhat 
more clumsy. The capsule is tightly stretched over the head, and the liga- 
mentum teres is well preserved. 

6. Discussion of another case. — ^Here the head does not touch the socket 
in its whole circumference, because the curves do not conform to the shape 
of the head. The socket is flat, like a dish, while the head is irregular. Tne 
capsule shows no more wrinkling, and it evidently shrinks up fairly quickly, 
but will not be firm enough to hold the head in motion for three or four 
months. 

Undoubtedly, the limb influences the formation of the joint: both play 
their parts. Muller has cured twenty-eight out of forty unilateral dislo- 
cations with perfect success. He always applies the dressing in extreme 
abduction external rotation, and with the Imee perfectly stretched. Only 
in this way can the head be fixed. 

Of the double cases he had five out of twenty-one perfect cures. He 
reproaches himself with having be^n treatment of chilaren who were too 
old, and with having made repositions of both legs on the same day, thus 
losing the opportunity of making use of walking. Nowadays he refuses 
to make repositions on children over five years old in cases of double dis- 
location. He has had perfect results in cases of one-sided dislocations in 
children of eight. 

To prepare by pulling he thinks unnecessary, except in cases of older 
children. The after treatment of babies is entirely imnecessary. — Abat. 
Archiv fur OHK Bd. I. Heft 2. 

3a. An Apparatus for the After Treatment of Congenital Luxation of the 
Hip. Deutsch. Med. Woch., February 19, 1903. 
L. Heusner demonstrates a new apparatus which he has found valuable 
in maintaining the legs and feet in proper position after the reduction of 
congenital hip dislocation by Lorenz's metnod. It consists of a leather 
corset for the trunk and pelvis, a short leather piece for thigh connected 



ABSTRACTS. 96 

to body-piece with springs, which prevent immoderate flexion, and keep 
the thighs spread out. Spinal springs extend downward over knee to foot. 
They tend to keep the feet and legs inverted. It is especially valuable in 
bilateral cases. — H. A, WUaon, Am. Med, 

33. A Note on Some Radiographs illustrating Congenital Dislocation of the 
Hip. By Morgan. British Medical Journal, April 1 1, 1903. 

Morgan illustrates his statement that radiography should assist the op- 
erator m the selection of suitable cases by a series of plates. Radiography 
is of value in determining the character of the reduction, and enables one to 
follow the case closely during the long period of after treatment. False posi- 
tion of the limbs during the exposure may lead to erroneous interpretation 
of the radiogram. — L. A. Weigel, Rochester, 

34. Congenital Luxation of the Hip. By Veau <Sb Cathala. Archives de Mid. 

des Enfants, No. 1, 1902. 
Anatomical examination of the right hip of a child which died one and 
one-half months after bloodless reduction. Concludes that true reduction 
is possible from anatomical standpoint, and that abduction and outward 
rotation is the best position in which to fix. — Abst. Zeitschr. fur Orth. Chir., 
xi. 3. 

35. Congenital Fissure of the Neck of the Femur. By Helblng. Deutsch. 

Med. Woch., No. 15, 1902. 
Four cases reported with radiograms. They were incomplete fissures at 
right angles to ttie axis of the neck, accompanied by diminution of the angle 
between neck and shaft, elevation of the trochanter and shortening of the 
femoral neck. Clinical picture similar to congenital luxation. No question 
of trauma or rachitis. Ijierapeutically suggests manuid osteoclasis of femoral 
neck.— Abst. Zeitschr. f&r Orth. Chir., xi. 3. 

36. Interpretations of Radiograms in Congenital Hip Luxations. By 

Gourdon. Rev. Mens, de Gynecol, No. 4, 1902. 
Draws attention to the discrepancy which may exist between the clinical 
characters and the appearance of the radiogram. Explains this by assum- 
ing that the hold ot femur on pelvis is maintained m early Ufe, not by a 
bony socket, but by tissue which is easily penetrated by the X-rays. He 
warns not to judge the result of reduction manoeuvres by radiogram alone. — 
Abst. Zeitschr. fur Orth. Chir., xi. 3. 

37. Owilym Q. Davis. Am. Med., May 30, 1903. 

Describes the methods of Paci, Heusner. and Lorenz in treatment of con- 
genital dislocation of the hip. — R. SotUter, Boston. 



HIP DISEASES. 

38. Etiology of Coxa Vara. By Haedke. Deutsch. Zeitschr. fur Chir., Bd. 66, 
Heft 2. 
Histological examination of a specimen of coxa vara obtained by resection 
from a seventeen-year-old patient. Found a condition similar to rickets, 
both macro- and microscopically. Concludes that coxa vara may develop 
at the age of puberty consequent upon the so-called late rickets, althousn 
the "juvenile osteomalacia" of Kocher is probably the explanation of the 
greater number. — Abst. Zeitschr. fur Orth. Chir., xi. 3. 



96 ABSTRACTS. 

39. Coxa Vara as a Deformity caused by Weight. By Blum. Langenbeck^M 

Archiv, 69th v. o3, N. 4. 

A boy nine years old, who four years previously had had tubercular coxitis, 
was brought to the Vienna public hospital because his mother thought that 
his left leg was some 4 cm. longer than the right. 

The examination had the following result. There was no lengthening of 
the left leg, but a shortening of the right leg, the trochanter of which was 
elevated. The cause of this was a right-sioed coxa vara, brought on un- 
doubtedly by a limited use of the left and an excessive use of the rieht leg. 
From this observation, and from the preparations of the Vienna coUection, 
the author discusses the classification and genesis of the deformity. He 
concludes that in many cases of atrophy of one extremity, no matter how 
caused, there forms a coxa vara of the other side. This is to be explained 
simply by the over-weighting of the sound extremity. 

It is of practical importance, because here the important antecedent symp- 
tom of Hofmeister — namely, the muscular atrophy on the coxa vara side — 
is wanting. 

Coxa vara is a statical deformity. The influence of the weight of the 
trunk is to be demonstrated in many cases, while other affections, which 
usually are considered as causative, exert only a predisposing influence. — 
Abat. Archiv fur Orth,, Bd. I. Heft 2. 

40. Essay on the Problem of Coxa Vara. Discussion at Lyon, 1903. By 

Yvemantt. 
A review of the anatomy of coxa vara in its various phases, f oUowing the 
essays of Jaboulay and Piqu6. He limits the term "coxa vara" to 



which come on during the growing period, and are caused by trophical dis- 
turbances. An outline of tne French literature on the subject is added. — 
Abst. Archiv fur Orth,, Bd. I. Heft 2. . 

41. Fractures of the Femoral Neck in Childhood and Youth. By Hoffa. pp. 
529. 

Since the introduction of the radiographic method, the number of reports 
of this condition has been greatly augmented. In addition to fifty-three 
cases previously collected by Gerstle (Inaug. Diss. Wiirzburg, 1899), twenty- 
five cases are collected from the literature, and given in full. Hoffa adds the 
reports of eleven cases of his own. 

Analysis of all the reported cases shows the greatest number to have 
occurred in the ages of ten to fifteen years. By far the greater number of 
cases are to be considered as epiphyseal separations. Of the eighty-seven 
reported cases, only four are held to be fractures of the neck. Of these, the 
greater number are incomplete breaks. 

Etiologically, the cases are divided into two groups. The first are those 
occurring in previously healthy children. The second comprises patients 
in whom there had existed some abnormity of the femoral neck, chiefly 
coxa vara. This is. therefore, regarded as of etiological importance in the 

f>roduction of this lesion. Frequently the symptoms are so vague, and so 
ittle disabling, that the diagnosis is not correctly made. Later in their 
course, these cases are looked upon as hip disease or as static coxa vara. 

Early recognition of these cases must be insisted upon. Elevation of 
the trochanter, shortening, shortened radius of rotation of the trochanter, 
crepitation, and possibly sugillation in the groin, are the s3rmptoms to be 
depended upon. The slight character of the disability must not be allowed 
to confuse. 

Later, tuberculous disease and static coxa vara must be excluded by the 
X-ray and by the absence of muscle spasm and atrophy of high degree. 

Recognized in the beginning, these cases should be treated as fractures. 
The necessity of preventing yielding of the femoral neck by the wearing of 
apparatus for at least a year afterward is emphasized. Seen late and uter 



ABSTRACTS. 97 

considerable deformity has occurred, resection or oblique subtrochanteric 
oBleotomy must be considered. — A. H. Freiberg, Cineinnati. 



KNEE. 

43. Luution of the Semilunar Cartilages of the Knee Joint. By Ferd. 
Schultze-Dinsberg. Archiv fur Orth,, Bd. I. Heft 2, 1903. 

A review of cases of loose semilunar cartilages. The present report is 
based on thirty-three cases confirmed by operation, two of which are the 
author's own. 

In the etiology he finds it chiefly in males, in youth, and always foUow- 
ing trauma. In twenty-five it was displaced inwards, and in eight out- 
wards. The symptoms are sudden pain after an accident, and a crushing 
noise. The patient feels something slip in the knee joint. It is charac- 
teristic that the joint cannot be extended. He distinguishes old cases from 
the new. In the new one finds effusion and the joint partly bent. There 
is an elastic and tender swelling next to the patella. After the swelling 
of the joint has gone down, the cartilage may oe palpated, best when the 
knee is bent. In old cases there are recurrent attacks of sudden pain fol- 
lowing motion, although the pain may in some cases remain permanent. 

The treatment may be conservative and operative. Ck>n8ervative treat- 
ment is advised when the signs are not marked and the diagnosis not dear. 
But in all cases where the displaced cartilage can be demonstrated opera- 
tion is advised. The operation may be removal or stitchins the cartilage 
in place. The prognosis is for an excellent result. — Henry Feise, Cleveland. 

43. Knee*joint Tuberculosis : Expectant Treatment or Operation. By Pro- 

fessor K6nig. 

A report in detail of a case of tuberculosis of the knee joint in which an 
excision was done. A discussion of operative vereue conservative treatment. 

The writer figures on two and a half to three years as the time necessary 
for cure, if conservative treatment is carried out. We may hope for a little 
motion, but the treatment is long and expensive; and in the end we may 
have to resect or amputate, after all. If we operate to remove the disease, 
with extirpation of tne process In or about the capsule, as well as upon the 
joint facets, we get a stiff leg, which may be shortened; but we can be prac- 
tically sure of quick result, and the patient soon becomes used to the altera- 
tion m walking. 

The writer explains the peat number of amputations in his clinic as due 
to the fact that conservative treatment had been used, and that resection 
for tuberculous joints had scarcely ever been done. — Henry Feiae, Cleveland, 

44. Qrowth and Structure of the I^wer Femur and Upper Tibial Epiphy- 

sis. By Ludloff. Bruna. Conirib,, 1903, vol. 38, No. 1. 

Normal knee joints of living models from one to eighty years have been 
studied by means of the X-rays. 

Both lateral and antero-posterior views have been taken. By means of 
these Ludloff proves that some appearances oi^inarily considered as patho- * 
logical — e,g., protuberances on the condyle between two and four years, 
and the so-called dark spot on the epiphysis — are quite normal. 

The foUowing summary is given: — 

1. The epiphyseal lines of the lower end of the femur and the upper end 
of the tibia remain till the age of fifteen. From two and one-half to eight 
years a very marked formation of bone is noticeable at these points. From 
seven to fifteen years the tubercle of the tibia develops very rapidlv. 

2. The middle of the condyles grows more rapidly from two to three and 
one-half veari^ the lateral parts in the fourth year, and after that an even 
growth of botn parts. 



98 ABSTRACTS. 

3. The middle of the condyles appears larger and has less thick spongy 
bone than the lateral parts. These show stronger longitudinal trabecule. 

4. There is a space in front in which no vertical structure was observed. 

5. Durins and after the third year this vertical structure becomes notice- 
able in the lower femur and upper tibial diaphysis. 

6. When both condyles have become distinguishable bones, vertical and 
oblique trabecule develop within the intercondyloid notch. 

7. During and after the twenty-fifth year the first appearances of atrophy 
are seen in the femoral epiphysis. — Abst. Archiv fur Orth., Bd. I. Heft 2. 

45. Habitual Luxation of the Patella (p. 452) . By Hannover Bade. ZeiUdtr, 

fur Orth, Chir., Stuttgart, 1903, Bd. XI. Heft 3. 
Four cases are reported, three being of traumatic origin and one con- 

genital. From the study of these cases as well as those reported in the 
terature, the author endeavors to draw conclusions reganling etiology 
and pathology of habitual dislocation of the patella as well as the symp- 
tomatology and treatment. 

Regarouijp; the etiology he finds the study of the literature shows decided 
influence of hereditv as regards the disposition to luxation, resembling in 
this wav congenital luxation of the hip. It is the author's opiniontnat 
habitual luxation of the patella is never congenital, but that a traumatic 
factor always exists in conjunction with hereditary predisposition. Con- 
genital luxations, not habitual, are placed by him in a separate class. 

The conditions which constitute the hereditary precusposition he con- 
siders to be delicate structure of the whole knee joint; great mobility of 
the patella, produced by laxity of ligaments and muscles, and especially 
the vastus intemus. 

Various combinations of these anatomical peculiarities may cause a patellar 
luxation to become habitual, which was produced by trauma in tne first 
instance. The traumatic element may be a direct external force or, on 
the other hand, an indirect one, exerting itself upon the knee joint through 
a particular position of the bod^. These two may act in conjunction. Direct 
force seems to preponderate m the production of the original dislocation. 
The reverse is true regarding the subsequent slippings of the pateUa. 

The symptomatology is carefully discussed, but without presentation of 
new facts. The same may be said of the treatment. A full bibliography 
is appended. — A. H. Freiberg, Cincinnati. 

46. Curvature of the Leg after Knee-joint Resections in Early Life. By 

Hofmeister. Brune, Contrib., vol. 37, Noe. 1 & 2. 

The disadvantage of resection and arthrectomy of the knee joint in early 
life are ehortening and curvature of the leg. The author discusses 125 cases, 
which could be examined after operation, covering a period of seventeen 
years. These were: — 

18 times (16.8%), absolutely straight legs. 

29 times (27.1%), straight to an angle of 165''. 

30 times (28%), moderate curving (160°-140**). 

48 times (44.9%), serious contractions of flexion (130^ and less). 

The review of tnese cases shows that, the younger the children, the more 
likely were the operations to be followed by secondary contractures. There 
were no contractures to be observed in children over fourteen. 

Three different groups can be distinguished: — 

1. That in which the contracture comes orL soon after operation, and 
grows worse rapidly. 

2. That in which the contraction begins very slowly, and extends over 
man3rvears. 

3. That which is caused by occasional trauma. 
He has found each of these croups many times. 

As to the question of etiology the author makes the following distinc- 



ABSTRACTS. 99 

tioi]«. In the first year there must be a locus minoris resittentut where 
a bending might take place. It is to be seen in a pathological softening of 
the bone in consequence of the tubercular process and aljM> in the physio- 
logical weakness in the neighborhood of the epiphyseal lines. 

Moreover, the forces at work — namely, the weight of the body and the 
pull of the flexors — act on these very places. 

The author points out the fact that the vertex of the bendins almost 
never corresponds with the epiphvseal line of the tibia, because the upper 
epiphysis of the tibia has to stand scarcely any pull of the flexors. In tnis 
wav, even those cases in which contractures occurred without the factor 
of body weight can be explained. 

By means of X-rays the contour should be carefully studied, in order 
that the bone mav be* attacked at the point of most extreme bending. Hof- 
meister advises the division of the flexors and their transplantation into 
the extensors. This rule holds good for every knee resection before the 
eighth year.— A6«/. Archiv /tir Orth., Bd. I. Heft 2. 

47. A New Method of Correcting Flexion Deformity at the Knee Joint. By 
Royal Whitman. Am. Jour. Med, Set., May, 1903. 
Royal Whitman describes this method, which consists of manual manip- 
ulation in preference to the use of mechanic appliances. The patient is 
placcNd prone upon a flat table, the operator then holds with one hand the 
head of the tibia firmly against the table, and with the ulnar border of the 
other begins forcible massage upon the contracted hamstrings, after the 
method employed (by Lorenz) in overcoming the resistance of the adductors 
in the operation of reduction of congenital dislocation of the hip. It is 
suitable to those cases where osteotomy is deemed unnecessary or inex- 
pedient. — H. A. Wilson, Am. Med. 



SHOULDER. 

48. On the Freeing of the Contractions of the Shoulder Joint. By Pro- 

fessor Dr. A. Ritschl, Freihurg.— Archiv filr Orth., Bd. I. Heft 2. 
The usual method of overcoming the contractions of the shoulder joint 
is partly manual and partly mechanical; and, in the mechanical part. Dr. 
Ritschl recommends, of the many kinds of apparatus, the one he ana Dr. 
Beely constructed. He considers both the manual and the mechanical 
methods necessary, but describes also the technique of a purely manual form 
of reduction, where one pushes the scapula backward with one hand and 
with the other raises the arm laterally. This has the advantage that 
one does not have to think of the horizontally fixed arm, and can con- 
centrate his attention more fully on the movement of the scapula. This 
method can be used in the horizontal as well as the recumbent position. — 
D. Townsend, Boston. 

49. Acquired Elevation of the Scapula. By Bender. Muen. Med. Woch., 

No. 9, 1902. 

The author reports a case in a girl of twelve years. Bender looks upon this 
case as acquired and of rachitic origin. He agrees in this with KOlliker, 
who first described it in 1898. Kdlliker considers increased curvature of the 
body, hook formation of the superior angle, enlargement of the coracoid 
process, and twisting forward of the glenoid fossa as characteristic of the 
rachitic deformity of the scapula. The elevation is ascribed to the hook- 
shaped upper angle clinging to the thorax, the enlarged coracoid applying 
itself to the clavicle from below. 

These ebaraeteristics, as weU as the absence of other malformations, are 



100 ABSTRACTS. 

held by Bender as differentiating the condition from the con^nital variety. 
The condition is very rare. Gross has described one case in addition to 
those of KOUiker and Bender. Photograms and radiograms. — Abst. Zeitachr. 
fur Orth. Chir,, xi. 3. 

50. Congenital Elevation of the Scapula. By Sick. Deuiach. ZeU. fur Chir., 

Bd. 67. 

Sick has observed two cases of this condition which are calculated to throw 
light on its causation. The first case is a bilateral one. Muscle anomalies 
were wanting in both cases, but deformity of the bones themselves, com- 
bined with incomplete closure of the vertebral canal, was present in both of 
them. In the bilateral case there was an hereditary element, while the 
other had the local hypertrichosis so often associated with spina bifida oc- 
culta. There appeared no occasion for operative interference in either 
case. The usefulness of the arms was sumcieutly improved by gynmas- 
tics. 

In the course of a critical examination of the fifty-seven reported cases 
of congenital elevation of the scapula, Sick finds that about two-thirds of 
them may be considered due to arrest of development. He leaves undecided 
the explanation of the remaining one-third, although he is inclined to con- 
sider them also as instances of arrested development, though of lesser degree. 
He holds the trapezius defects, used by Kauscn in his explanation, as merely 
faculative accompaniments of the arrests of development in the spine and 
scapula, respectively. — Abst. Zeitschr. fur Orth. Chir., xi. 3. 

51. On the Etiology of Double Congenital Elevation of the Scapulae. By 

H. Mohr. Org. fur OHh. Chir., vol. ii.. No. 2. 

Heretofore only five cases of double elevation of the scapulae have been 
observed. In the case of a twenty-two-year-old working-woman the de- 
formity was congenital, but is said to have erown worse. Vertebral curva- 
tures came on later. From an early age she liked to rest her arms upon her 
back. Her head is bent forward, the shoulder line in the neck region has 
vanished, and the neck itself is shortened and broadened. The scapulae, 
especially the left one, are of abnormal height. An upward motion of the 
arms is soon followed bv a corresponding motion of the scapulae. 

As to the Question of etiology, the author thinks the symptoms of the case 
are explained by the Sprengel theory of " intra-uterine pressure." Mus- 
cular atrophy and developmental changes in the scapulae are to be consid- 
ered secondary symptoms. The lordosis which has been observed seems 
to compensate the forward bending of the head. — Abst. Archiv fur Orth., Bd. 
I. Heft 2. 



FOOT. 

Sa. The Importance of the Tibialis Posticus and the Plantar Muscles in 
Flat Foot. By Nicoladoni. Deutsch. ZeU. fur Chir., Bd, 67. 
Nicoladoni was one of the first to express belief in the importance of the 
tibialis posticus in maintaining the arch of the foot, on account of the way it 
spreads fanlike over the Sistragular head into the tarsus. From this he deduced 
the procedure of grafting half of the Achillis tendo upon the posticus. 
Observations upon paralysis cases and other considerations also nave led 
him to modify his opinion to the extent of believine the soIq muscles to be 
at least as important in this regard as the posticus. He finds that permanent 
loss of the tibialis posticus is not of necessity followed by flat foot, while 
the reverse is true of the sole muscles. This greatly diminishes the impor- 
tance of the tibialis posticus in etiology, but also the treatment of flat foot. 
More rational than strengthening the posticus by a graft would therefore be 



ABSTRACTS. 101 

the temporary exclusion of the triceps sur», which is the antasonist of the 
sole muscles. For severe cases he proposes open tenotomy of the tendo 
Achillis, with temporary displacement of the proximal end under the crural 
fascia to prevent premature union. When, as the result of function, nes 
calcaneus nas developed, the reunion of the tendo Achillis may be under- 
taken.— Ab«<. Zeitsckr. fur Orth, Chir., xi. 3. 

53. On the Mechanism of Flat Foot By S. Petersen. Von Langenbeek^9 

Records, vol. 69, Nos. 1 A 2. 
There are four different changes in fiat-foot joints in consequence of weight. 

(1) A bendinff in the upper ankle joint between the leg and the ankle 
bone, whereby the head of the astraeulus is lowered. 

(2) A pronation in the lower ankle joint between the astragulus and the 
OB caJcis, whereby the inner border of the foot becomes lowered. 

(3) A yielding within Chopart's joint, which brings about a flattening of 
the whole foot vault and puts an mtense strain upon the calcaneal, navic- 
ular, and plantar ligaments. 

(4) An abduction at Chopart's joint, which is brought about by different 
motions at Chopart's joint, which causes a flattening of the inner border of 
the foot. 

Flat foot represents a pathological extreme beyond these four phjrsiolog- 
ical motions and a fixation of this position that is a subluxation. It is spoken 
of, therefore, as a pes flexus, pronatus, reflexus, or abductus. These names 
at once indicate tne clinical symptoms and especially the points of pain, 
namely: external malleolus, pressure on the calcaneus; centre of the sole, 
pulling on the calcaneal, navicular, and plantar ligaments; under surface of 
the heel, pulling of the tendons and muscular attaclmients. 

Flat foot is entirely a weight deformity, caused by a disproportion between 
the resistance of the' supporting structures and the amount of weight work- 
ing upon it. Rickets and puberty are predisposing factors. — Abat Archiv 
furOrth.,Bd,l,lleft2, 

54. Plat-foot Support made of Celloloid and Steel Wire. Muen. Med, Woch,, 

February 17, 1903. 
The pains of flat feet can be found in various portions of the foot, and do 
not in the least correspond to the degree of pes planus. Sometimes the 
greatest pains are found in cases preserving a good arch. An important 
diagnostic sign is that the pain is complained of only during walking ana stand- 
ing, and ceases as soon as the patient rests. The cause of the pain lies in 
the small footbones pressing against each other, and in an excessive pull- 
ing of some of the ligaments. The diagnosis of flat foot is, however, only 
proved by the results of rationally conducted treatment, which must con- 
sist of the production of an arch as high as possible. The insole must be 
made accurately from a plaster of Paris cast, and even then fully 20 per cent, 
of the soles require additional correction. In cases of valgus positions 
of the foot the insole must form an oblique plane, and must have a lateral 
edge to prevent a gliding off of the foot. As best material, he recommends 
a solution of celluloid and acetone over Langsgurte. Wires are introduced 
to strengthen the tension of the arch. F. Lange reports very good results. 
Of 400 patients thus afflicted, only 8 failed to improve, and a number were 
cured. For good results, however, it is necessary for the patient to be under 
daily supervision for eight days, for the physician to make the cast and model 
himself, sometimes also the insole, and for the patient to wear the insole for 
several years, [e. l.] — H. A, Wilson, Am. Med. 

55. Some New Apparatus for the Forcible Correction of Defdrmed Feet 

By Vogel. p. 608, Zeitschr. fur Orth. Chir., xi. 3. 
In place of the Lorens ostoclast three instruments are designed for the 
correction of pes varus, planus, and excavatus, respectively. 



102 ABSTRACTS. 

For the first two the apparatus consists of a lon^ handle terminating in 
a pad of suitable shape, and a curved arm terminatmg in a padded crutch. 
The latter is made to approximate the former by means of a screw on the. 
shaft of the handle. The foot is then wrenched into shape, the pad on the 
end of the handle acting as a fulcrum. 

For cavus the apparatus resembles closely in principle the apparatus of 
Redard. The heel and ball of the foot resting on pads, a third pad is made 
to press upon the dorsum by means of a compouna lever acting from below. 
The illustrations are self-explanatory. — A. H. Freiburg, Cincinnati, 



RICKETS. 

56. The Cause of the Disappeaiance of Knock-knee when the Knee is flexed. 

By Kumisson. Remie dVrthopedie, March, 1903. 
That this occurs no one doubts, but the cause is variously accounted 
for. After quotinj; other authors, Kirmisson explains the phenomenon bv 
the fact that the mternal condyle of the femur is lower than the external. 
In knock-knee, due to enlargement of or lowering of the internal condyle 
of the femur, adduction of the tibia takes place with flexion of the knee. 
Kirmisson demonstrates this very simply and clearly by a piece of paper. — 
Robert Soutter, Boston, 

57. Prolonged Evolution of Knock-knee. By L. Ombredaune. Rev. d *Orth., 

March, 1903. 

Dr. Ombredaune considers most carefully and in extreme detail the de- 
velopment of knock-knee with minute description of cases and the method 
of treatment, especially the comparison of McEwen's and Ogston's opera- 
tions. 

Ombredaune favors Ogston's operation in severe cases, for in osteotomy 
of the internal condyle the line of the bone is preserved. 

Knock-knee may mcrease after a person has attained his growth. In ex- 
treme cases McEwen's operation is less advantageous, and Ogston's more 
and more indicated as the deformity is increased. — Robert SotUter, Boston, 

TORTICOLLIS. 

5$. *« Congenital** Wryneck. Zeitschr. fur Orth. Chir., 1903, xi. 416. 

H. Maass has studied forty cases of wryneck in the new-bom from the 
standpoint of their etiology. Twenty-three of these were breech presen- 
tations, five were forceps deliveries. He considers the cause of this con- 
dition to lie in pathologic changes arising in the sternomastoid, as the result 
of birth trauma. A few of the cases may be due to infectious myositis in 
the course of an intrariiterine injurv, but this is relatively seldom. [■. l.] — 
H. A. Wilson, Am. Med. 



PARALYSIS. 

59. Treatment of Infantile Spastic Paralysis. Liverpool Med. Chir. Jour,, 
October, 1902. 
R. Jones believes a large proportion of children suiffering from severe 
forms of this affection may be transformed into useful members of the com- 
munity, and enabled to walk with little deformity, many requiring only 
the aid to be derived from one or two sticks. Active treatment may be 
needed for nearly two years. Hemiplegia usually affects the arm much 



ABSTRACTS. 103 

more than the leg, and the treatment is less promising than in dipiej^c cases. 
If the patient can do more with the hand than at some previous tmie, suc- 
cess of treatment is assured. When any voluntary relaxation of spasm 
exists apart from associated movement on the opposite side, treatment is 
emphatically indicated. Since the dominant deformity is pronation and 
carpal flexion, the elbow must be fixed supine, and the wrist and fingers 
fully extended. Prolonged fixation of spastic muscles in a position opposed 
to their contraction lessens the severity of the spasm. Elxtension may be 
discarded in twelve months. If success cannot be predicted at this stage, 
tenotomy or tendon transplantation should be perfonned. After opera- 
tion, over-extension should be practised for a few weeks, and, in order to 
prevent adhesions, the wrist should be moved about. Movements from 
simple to complex should be taught. Division of the tendo Achillis con- 
trols spasm not only in the calf muscles, but influences spasm elsewhere. 
In spastic paraplegia the splint should keep the limb in marked abduction. 
If there are anv obstacles to easy extension of the knees, the hamstring 
must be dividecl by open incisions on each side of the popliteal space. The 
patient should be kept on the abduction frame at least three montns. Move- 
ments must then be sedulously practised, and finally the little patient can 
be taught to walls. Much depends on the nurse. The mental condition 
improves with the ph3rsical. Complete recovery in spastic paraplegia is, 
of course, impossible. — H. A. WiUon, Am. Med. 

60. Poliencephalomyelitis and Allied Conditions. By £. W. Taylor. B, M. 

& S. Jour., June 11-18, 1903. 

Taylor believes that a l&rse group of affections of the central ner- 
vous system exists, provisionaUy to be regarded as inflammatory, in which 
may be included encephalitis, poliencephalitis (superior and inferior), pol- 
iencephalomyelitis, poliomyelitis, encepnalomyelitis, and. with reservations. 
Landry's paralysis, and possibly myasthenia gravis, and certain peripheral 
nerve infections. These should be regarded as essentially identical, differ- 
ing only in symptomatic expression. The evidence for this lies in the sim- 
ultaneous involvement in individual cases of various portions of the ner- 
vous system, a notable example of which is given in poliencephalomyelitis. 

We should gain in our understanding of these and other affections if we 
adopted a classification based on pathologic alterations and on etiology, 
whenever possible, rather than on clinical symptoms determined by ana- 
tomic subdivisions. Admitting a somewhat definite pathologic alteration 
of the nature of inflammation as a fairly constant factor, we may assume 
the existence of a common exciting, probably toxic, cause. The nature 
of this cause is practically unknown, its manifestations are not always uni- 
form, and our final understanding of the distribution and prognosis of these 
affections must depend, first, upon our knowledge of these exciting causes, 
and, second, upon the nature of individual susceptibility and resistance. 
[h. m.] — Abst. Am. Med. 

TENDONS AND MUSCLES. 

61. Osteal Tendon TransplanUtidn. By J. Wolff. Deutsch. Med. Woch., No. 

18, 1902. 
This article antagonizes the too optimistic contributions on tendon trans- 
plantation of late years, and emphasizes the fact that no absolute gain of 
power is achieved thereby, but only a change in its distribution. L^ pos- 
sible still is it to acquire an absolute increase in power when the muscle 
which is to supply it is itself paretic. For this reason he holds it better 
to simplv improve the position oy shortening tendons or by displacing such 
as arc shortened without considering the functional activity of the respec- 
tive muscles. In place of the periosteal method of Lange, he proposes 



104 ABSTRACTS. 

the fixation of the tendon in a groove cut in the bone. He reports four cases 
of paral3rtic extremities thus successfully operated upon. — Abst. ZeiUdw, 
fur Orth. Chir., xi. 3. 

6a. Histological Investigations on the Repair of Tendon Wounds and De- 
fects. By Seggel. Beitr. «. klin, Chir., Bd. 37, Heft 1-2. 

Exhaustive studv of the repair of tendon wounds, including tenotom]^, 
tendon suture, and aU the methods of tendon plastics. According to tms 
the development of a new tendon occurs by the organization of the blood 
poured out from the sheath and the divided tendon. This fills the whole 
tendon sheath. On the tenth day the inner layers of the tendon sheath 
consist of long, slender, spindle cells, with marked fibrillation. By the 
thirtieth day tne tendon regeneration \a already far advanced, compact 
tendon bundles growing distally push the loose granulation tissue ahead. 
By the thirty-eighth day the regeneration extends to the whole cross sec- 
tion. By the fiftieth day the chmax of organization ts reached, the tissue 
remaining either unchanged or becoming of looser texture. Seggel con- 
cludes that the tendons possess a very marked power of regeneration. This 
begins, however, only secondarily after the lapse of eight to ten days, and 
remains for a long time in one state. 

The practical application of these investigations is as follows: Long fixa^ 
tion is necessary. Not even before the fortieth dav is the use of the tendon 
rational. In view of the ^at rdle played by tne tendon sheath in the 
process of repair, its integrity is of importance. However, the sheath has 
nothing to do with the actual regeneration. For this reason real regeneration 
may be expected in osteal and periost-eal tendon transplantation. Func- 
tional use does not seem to make any great difference in the healing process, 
nor does this seem to depend upon the tension. The same may be said of 
foreign bodies. The primary quality of the regeneration is not determined 
by these external conoitions, but the tpumtityof material produced is. These 
thinss must be carefulhr considered m doin^j; operative work upon tendons 
for this resson. — Abst. Zeit. fur Orth. Chir., xi. 3. 

63. On the Technique of Lengthening of Tendons by Tendon Transplanta- 

tion. By C. Springer. 6 iUustrations. Arckiv fur Orth., Bd. I. Heft 1. 
Springer uses the Z method of Beyer in pure equinus cases, and such as 
are complicated with valgus or varus. His method consists in making 
a subcutaneous cross-cut with a tenotome half through the tendo Achillis 
(for valgus position on the inner side, and for varus the outer side) above, 
and a sufficient distance below on the opposite side, and then by a strong 
dorsal flexion of the foot a subcutaneous 8ei>aration of the longitudinal 
fibres takes place, accompanied by an evident jerk. This method Springer 
has used as weU for torticollis, Duprey's contraction, and joint contractions. 
After the Z incision is made, the peronei are sewed to the tendo AchiUis. 
He favors the Z method of Beyer because it is easily performed, it leaves 
a suitable surface wound for the sewing on of the peronei, the whole of the 
material is used for the lengthening, the whole tendon when lengthened 
represents half of the original tendon, the portion not lengthened is let alone, 
and, when healed, the tendon is one-sixth stronger than if done by Priolean's 
method. — David Toumsend^ Boston. 

64. The Elasticity of Muscles and ito Importance in Surgery. By Tillman. 

Von Langenbeck*s Archiv, vol. 69, Nos. 1 A 2. 
The position of eauilibrium in the joints depends upon (1) the manner 
in whicn those muscles which are in a per^tual state of tension keep the 
balance, and (2) upon gravity. The elasticity of the muscle puts it atwavs 
''on the stretch," even when the joint is at rest. This accounts for the 
fact that the voluntary contractions, in spite of their suddenness, take place 
gently and gradually, and not jerkily. 



ABSTRACTS. 106 

Tillman examined the results of Mosso's experiments with a myotono- 
meter by experimenting himself. In agreement with Moaso he found that 
the muscle, whether passively extendea or put on the stretch b^ the ten- 
sion of its antagonistic groups, remained in a state of "after extension/' while 
the antagonistic muscles remained in contraction until another active con- 
traction equalized the differences. . 

Other experiments on the finger muscles of a living subject showed that 
a disturbance of the "balance position" for a short time (i.e., perhaps twenty 
seconds) had no positive effect, while after a longer interference the finjier 
had not come back to its normal position even after six minutes. This 
not only depends upon the "after extension,'' but also upon the shortening 
of the antagonizing muscles, there beins a residuarv shortening, so that 
the position of equilibrium is attained in less time if the stretching cord has 
been injured. 

The difference of Triepel's results seems to be explained by the fact that 
the latter experimented on the muscles of an amputated extremity. 

The contractibiiity of muscles under normal conditions seems to show 
that lasting injuries do not result from a disturbance of equilibrium. It 
will be different if this contractibiiity has been lost. For this reason a long- 
continued fixed dressing has ereat disadvant^^; and, on the other hand, 
the ambulatory treatment of fractures has had good results. 

We leam this same principle from every-dtiy experience, and the same 
lesaon is taught in hospital oDservations, — e.g., in contracted peroneal mus- 
cles, brought on by their exercising a one-sided function for too long a time. 
Cases of this kind can be cured as tong as no permanent pathologicaTchanges 
have taken place. 

A continued shortening usually does not cause a disturbance of nourish- 
ment, but a continued extension often causes serious atrophy. 

From these investigations it is evident that a plaster of Paris dressing 
in a position of rest should be emploved if contractures are to be avoided. 

The author defines habitual scoliosis as a disturbance of equilibrium 
caused by the antagonism of the lone muscles of the back, brought on by 
an incorrect attitude in sitting. HaUux valgus and hamn^^r toe are easily 
explained by the perpetual one-sided contraction of muscles. The same 
law is in force in talipes and flat foot, in the former the tibiales anterior and 
posterior and in the latter the peronei beins continuously contracted. It 
is more difficult, however, to trace genu valgum back to a primary con- 
traction of the biceps. — Abst. Arehiv fur Orth., Bd. I. Heft 2. 

65. Advances in the Treatment of Paralytic Deformities. By A. H. Tubby. 
The Lancet, London, March 28, 1903. 
Tubby discusses the treatment of paralytic deformities following infantile 
paralysis or anterior poliomyelitis or the spastic t}rpe, hemiplegia, cerebral 
diplegia, and those due to injuries of the nerves. He describes the method 
of tendon grafting, giving itis history. The rationale is to utilize what is 
ill-directed voluntary movement, and restore the balance of muscle as far 
as possible in the affected part, so that the active muscles are not brought 
to work against the enfeebled ones, thus producing deformities. The brain, 
he thinks, becomes readily aware of the new conditions of movements bv 
education. The methods and technique of operation are described. He calls 
attention particularly to the necessity of reshaping the joint surface in old 
cases and putting the foot or the limb in fully corrected position, and to 
leave no tension of the reinforcing muscle. Arthrodesis is useful in some 
ankylosed joint cases | but he does not believe in its propriety in the knee, 
because the long, straight shaft of the bone so formed is inconvenient, brittle 
from paralytic changes, and liable to fracture. He would prefer to use 
meclumical supports with a rin^-catch at the knee joint or to transplant 
portions of the fascia from the sides and back of the joint into the patella. 
At the ankle, however, it is a valuable measure, because it gives a suitable 



lOe ABSTRACTS. 

basifl of support. In Bpaatic paralysis the whole secret of success of tenot- 
omy consists in preventing elongation of the bond of union and carefully 
guarding it until equilibrium of the opposing groups of muscles has been 
established. If there is fair intellectual development and no fits, it results 
in nothing else but good physicalh' and mentally, because the more these 
patients are able to get about and' be in touch with others, the more they 
unprove. In cases where it is possible to restore the continuity of the nerve, 
muscle grafting is the method for overcoming the difficulties; and he reports 
a case in point. — Abst. Jour. Am. Med. Aas'n. 

M. On the Position of the Tendo AchUlis by Different Position s of the Feet 
and by Contraction of the Calf Muscles. By Dr. L. Athabegian 
(Schuscha). Archiv fur Orth., Bd. I. Heft 1. 
Dr. Athabegian in this paper discusses the literature of the subiect, the 
technique emploved in measuring, and the different points measured, length 
of tibia and tendo Achillis, the relation of the insertion of the tendo Achillia 
to the ankle joint in the different positions of the foot, and the changes of 
the relations of tendo Achillis in various positions of the foot and Icnee. 
The article is copiouslv illustrated by drawings, figures, and tables of measure- 
ments. — D. Toivnsendf Boston. 



MISCELLANEOUS. 

67. Clinical and Experimental Contribution to the Study of the Lesions of 
Traumatic Origin, of the Brachial Plexus (pp. 1-33). By R. Galeaxzi. 
Arch, di Ortopedia, Milano, 1903, xx. fasc. 1. 

The cases observed were: (1) a syndrome of D4j4rine-Klumpke, provoked 
by a wound of the neck; (2) gunshot wound in the left carotid region with 
lesion of the vagus and the brachial plexus; (3) luxation, by rotation to the 
left, of the fifth cervical vertebra witn an elevated position of the articular 
apophysis; paralysis of the brachial plexus of complex type, but generally 
extreme I (4) luxation^ with rotation to the ri^ht, of the tnird cervical ver- 
tebra, with its straddling the articular apophysis; paresthesia from compres- 
sion of the fourth cervical root; reduction; recoveiy. 

The paresis and muscular paralysis may be explained by stretchine or 
direct compression from the luxated vertebrsp or by the quite abunaant 
extra-meduilarv extravasations. In almost all these cases there were symp- 
toms of medullary lesion with those of the radices, so that it is difficult to 
distinguish the spinal lesions from those of the radices. Few cases have been 
described where the root symptoms were as clear as in these. From them it 
would result that it is possible for a paralysis of the roots to arise from the 
same cause which produces the luxation of the cervical vertebne; that 
is, constant compression. This is confirmed by the clinical histories and on 
observations on the cadavers, and is also evident in the preparations of lux- 
ations which the author has been able to observe. The few surgical inter- 
ventions recorded give encouraging results. The difficulty is in nnding the 
seat of the lesion and determining its degree. 

68. Orthopedic Surgical Treatment of Paralysis of the Radial Nerve (pp. 42- 

56). Arch, di Ortopedia. By Alessandrini. 
Most cases of paralysis in children come from poliomyelitis. In the sta- 
tistics of Kermisson, of 179 cases of infantile paralysis, only 16 are referred 
to the upper articulation. This agrees with other authors. In Alessandrini's 
cases he found only 2 cases of the superior articulation out of about 70 cases. 
Much credit is due to Drobnik, who practised a transplantation in a case 
of partial paralysis of the radial nerve; and Alessandrini has treated this 
question amply in his communication: "Interosseous Retrograde Transplan- 
tation of the Long Extensor of the Hallux in 'Pes Valgus Paralyticus.' " 



ABSTRACTS. 107 

A boy of five yean entered August 19. 1902. Six months old, he had been 
attacked by an intense fever, after whicn he lost completely the motility of 
the ann and right leg. In time there was some amelioration. At present 
there is a tendency to recline head to the left and roll it to the risht; right 
foot in pure equinus position; the rifht is pressed to the body ana in inter- 
nal rotation; the fore arm and hancT in manifest pronation; extension im- 
possible, some flexion. Operation August 26, 1902: Alessandrini isolated 
almost all of the longus palmaris with median incision, then passed between 
the deep flexor of the finf^ers and the lone flexor of the thumb, prepaied the 
interosseous ligament, which he split, avoiding the artery and tbe interosseous 
nerve. He then dissected with median dorsal incision the common exten- 
sor of the fingers; and, passing between the abductor and the lon^^ extensor 
of the thumb, he prepared the interosseous ligament of the dorsal side. The 
tendon of the longus palmaris was then cut above the transverse lif^ament 
of the carpus, and, passing it through the interosseous ligament, it was 
fixed in a boutonni^ of the common extensor of the fingers above the point 
whue this muscle untwists into its tendons, but quite a space above. The 
part above the tendon he divided into two, the first of which he fixed with 
sutures to the tendons of the common extensor of the fincers and anasto- 
mosed, the other with the long abductor of the thumb. He took care to 
avoid the shortening of the tendons, and applied an apparatus which kept 
the hand hvper^«xtended and in supination and the fore arm flexed to the 
ann with tnat in exaggerated supination. The result was most favorable. 
The sutures were removed on the twenty-eighth day, and electricity and 
massage used daily, keeping the hand in super-extension from sitting to 
sitting by apparatus. The patient was dismissed in about two months with 
the fimction re-established »n Mo, A month after the result was maintained. 

00. Suture of the Brachial Plexus for Birth Palsy. BriHah Medical Journal, 
February 7, 1903. 
Eennedv states that many of these cases recover without treatment. Many, 
however, fail to recover; and he is doubtful as to the efficacy of electrical 
treatment in birth palsies, though electricity is of undoubted value for diag- 
nostic and pro^ostic purposes. He holds that the only rational way to 
treat birth palsies is that of injuries to peripheral nerves in seneral. No 
operation snould be attempted until sufficient lapse of time has occurred 
to determine whether electric reactions will indicate an approaching recov- 
ery of the muscles. By the time the child is two months of age, ordinary 
electric reactions of the child's muscles are sufficientlv stable to determine 
whether the nerve and muscles properlv respond. If after this age there 
be no response to the faradic current, although of course the galvanic cur- 
rent evokes good contractions, it is safer to proceed with operation than to 
put it ofif in the further hope of recovery. Comparatively few secondary 
operations on the brachial plexus are reported, ana in most of these the sub- 
sequent history of the cases is not given. The author has operated on three 
cases, but in only one has sufficient time elapsed for recovery to be well ad- 
vanced. In this case, commencing restoration was first noticed about twelve 
weeks after the operation, and now after nine months' recovery is almost 
complete. The operation is described in detail. The author advocates 
exposing the cords of the brachial plexus, following them in the region where 
the injury is probable, breaking up idl adhesions. If masses of cicatrices 
have occurred in the iniiued nerves, these should be resected, and the sev- 
ered cords approximated by sutures, [a. b. c.}—Ah9t, Am, Meet. 

70. On the Relation between the Supra-renal Qlands and the Qfowth of the 

Body to Gigantic Proportions. By Tinser. Bruns, Eee,, vol. 37, p. 182. 

Of the "blood glands," the thyroid, the hypoph3rBiB, the thymus, and the 

testicle have been known for some time to exert an influence in anomalies 

of growth. The author now points out that the suprarrenal has also an influ- 



108 ABSTRACTS. 

ence of this kind. He reports an observation of his own, and g^ves a review 
of other published cases. 

In the Tubingen hoflpital there was a boy of five and a half years, wdght 
30 kc. (86 pounds), heisht 138 cm. (4 feet 7i inches), making nun i^pear to 
be aoout fifteen years old. 

Post mortem. — ^A tumor of the left supra-renal gland nearly the sise of a 
child's head was found. The histolo^cal examination seemed to show an 
epithelical neoplasm of the type of malignant adenoma. An eartirpation dur- 
ing kq^arotomv was impossible on account of the numerous metastases in- 
v<3ving the inferior vena cava. 

The patient had suffered only one year before his death with headache 
and pam in the left side of the abdomen. The author concludes that the 
blooa glands, as a whole, are in close connection with one another, and may 
be supplementarv to each other, a certain reciprocity existing between them. 
He thinks that aU of them may mfluence the growth of the body^ their hjrper^ 
trophy having connection with gigantism, and their atrophy with pygmean 
growths.— A6«<. Archiv fur Or<A., M. I. Heft 2. 

71. On Angiosderoeis of the Iliac Veins, with a Paper on the Treatment of 
Temporary Intermittent Limping and on the Qroup of Symptoms. By 
N. Ortner. Published by Stokes ^ Adam. Collect. Clin. Papers, New 
Series, No. 347. 
After the discussion of a case and autopsy in a very interesting way, the 
author discusses the analogy between these facts and the intermittent clau- 
dication of the muscles ofthe lower extremities (Charcot, E^, Goldflam). 
This latter is caused by an ischflBmia of the affected parts of the extremities 
because of disease of the arteries and cramps of the arteries and veins dur- 
ing the movements of the limbs. The author explains the condition of his 
pi^ient during abdominal digestion on the ground of an ischsmia oocurrins 
while the abdomen is engag^ in its function. — Abet. Archiv fur Orih., Bd. I. 
Heft 2. 

79. A Case of Intermittent Claudication. Dissertation, Jena, 1002. By 
Nierling. 
The author comes to the following conclusions : — 

1. The aspect of intermittent claudication is not always the same. Either 
the 83rmptoms of sensation or pain and spasm ma^ be the prevailing ones. 
The whole system complex is not always developed m its entirety. 

2. The onset may be sudden, without any previous disturbance whatever, 
excited, it may be, by cold or b]^ nervous over-exertion. 

3. Changes in the foot arteries are not always to be detected by palpa- 
tion or the X-ray. 

4. Standing occupation seems to cause the patients more annoyance than 
ordinary waUong. 

5. Syphilis seems not to be without importance in the origin of the dis- 



6. The phenomena of intermittent claudication are to be attributed to 
faulty blood supply of the lower extremities. 

7. This is caused not by arterio-sclerosis alone, by the permanent narrow- 
ing of the vessel walls, ft is very likely that a functional agent, the chang- 
ing ph3rsiological function of the vessel walls, plays a very important role. 

8. It is not impossible that the disease is a functional neurosis, a symptom 
of one, or a vaso-motor neurosis of this character. — Abet. Zeitechr. fur Orth. 
Chir.f xi. 3. 



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yoi.iniB I. NOVEMBEB, 1903. Kvmbkh, S. 

The American Journal ^ 
Orthopedic Surgery 



CHRONIC VILLOUS ARTHRITIS, WITH SPECIAL 

REFERENCE TO ITS ETIOLOGY AND 

PATHOLOGY. 

CHARLES F. PAINTER, M.D., AND WILLIAM G. ERVING, M.D., 
OF BOSTON. 

In a paper published in the Boston Medical and Surgical 
Journal iinder date of March 19, 1903, the authors under- 
took to review the literature of Lipoma arborescens, and to 
supplement this with a report of seven cases which had come 
to operation. In that series the lipomata were discrete, usu- 
ally single growths, and would be better described as fatty 
tumors than as the arborescent lipoma. The pathological 
investigation of these growths, however, shows that they 
were undoubtedly degenerated villi and not true tumor foi^ 
mations. They had, however, lost all gross resemblance to 
the original fringes from which they were developed. As dis- 
crete tumors, they gave rise to rather different symptoms 
than the ordinary synovial fringe. 

In the literature there are several authors who believe that 
the fatty growths foimd in the joints are true tumors, which 
push their way in from the outside rather than develop 
from the inside. The article just referred to, we think, shows 
that these growths are the result of an hypertrophy of synovial 
villi. There are, clinically, a great many cases where the 

Presented at the Seventeenth Annual Meeting of the ABsooiation, Washington, 
IhC.. May 11-14, 1903. 



110 CHRONIC VILLOUS ARTHRITIS. 

villi are hypertrophied; and where the isolated, single lipomata 
are not present. The purpose of this article is to report a study 
of thirty-three cases of hypertrophied villi,* caused by various 
conditions, and to show, if possible, the varying etiology of 
this joint disease, and to put on record the pathological find- 
ings observed in these cases. 

Etiology. — ^Local tissue changes are effected in many differ- 
ent ways. In the condition here being considered, it would 
seem that the causes might be classified imder the heads of 
(I.) traumata, (II.) infections, and (III.) diathetic conditions. 

I. Trauma. Under the head of traumata are to be con- 
sidered (1) direct blows and injuries to a joint and (2) indu'ect 
injuries, the consequence of strain to the joint from faulty 
position resulting in impairment of fimction. Traumata also 
result from within the joint itself, as when (3) a semilunar 
cartilage becomes partially detached, causing impairment 
of the function and, in some cases, direct violence to the sy- 
novial membrane. (4) Loose bodies in a joint, the so-called 
joint "mice," are capable of causing synovial irritation. 
(5) Forcible wrenches or lacerations of the ligaments of the 
joints (either the supporting external or the internal) weaken 
the joint, cause a relaxation of the ligaments, impair the 
function, and may thus cause the villous hypertrophy. (6) 
Flat and pronated feet, by causing strain to the internal 
lateral ligaments of the knee, are common causes of congested 
or hypersemic knees, particularly in stout and flabby individ- 
uals, usually women. This condition is not uncommonly an 
accompaniment of the early convalescence from the confine- 
ment of pregnancy (e.j., No. 12), f and is also occasionally met 
with at puberty in rapidly growing but sickly children, where 
there is much muscular and ligamentous loss of tone. We 
have also observed it in a young woman in whom there was 
some knock-knee and elongation of the patellar tendon. This 

* Seyen baye been reported as aboye stated. The otber twenty-six haye not be- 
fore been reported. 

t The detailed aoconnt of this and the following oases referred to in the text can 
be found in the MtdHeal New* for Noyember, 1903 (two numbers). Also the abstract of 
the literature referred to in the bibliography. This is omitted here for lack of space. 



C. F. PAINTER AND W. G. ERVING. Ill 

was accompanied by considerable relaxation of the capsule 
of the knee joint and thickening of that portion of it on either 
side of this tendon at the level of the line of the joint. Fibrin- 
ous clots cause sufficient trauma to irritate the synovia. 

II. Infections. Among infections first of all should be placed 
(1) tuberculosis. Some tuberculous joints show it more than 
others. As a rule, those in which the process has shown it- 
self primarily in the soft structures of the joint rather than 
in the bones illustrate villous hypertrophy most decidedly- 
Usually, a tuberculous condition can be readily diagnosed 
clinically, and the aid of the microscope is rarely necessary. 
The difficulty of the histological diagnosis of these fringes has 
been demonstrated once in our experience where excision of 
the knee was performed following a pathological diagnosis 
of joint tuberculosis. The subsequent history made the diag- 
nosis of joint syphilis much more probable (see Case 2). It 
has been shown occasionally that tuberculosis has grafted 
itself upon an ordinary hypertrophied fringe, which has evi- 
dently been pre-existent to the tuberculosis. (2) Gonorrhoea, 
and probably other infective processes, cause villous hyper- 
trophy. The writers have seen this in two cases here reported; 
namely, Nos. 21 and 22. In the more rapidly developing in- 
flammatory conditions there is not as much villous enlargement 
as in the more chronic processes, probably because the inva- 
sion of the synovial membrane with such numbers of round 
cells prevents the folding up of the membrane, and the vascular 
changes are not so conspicuous as in the subacute processes 
heretofore mentioned. (3) Sjrphilis. The extensive hyper- 
trophy of the synovial membrane due to syphilis has been 
mistaken both before and after exploration of the joint for 
rheumatoid arthritis. In one of our cases the correct diagnosis 
was arrived at when, one and one-half years after the arthrot- 
omy, the tissues of the knee broke down and typical syphil- 
itic ulcerations appeared. These cleared up with great prompt- 
ness, and the swelling of the knee almost entirely disappeared 
under large doses of the iodide {e,g,, 2 and 6). 

III. Diathetic. Under this head we have rheumatoid arthritis 



112 CHRONIC Vn.LOUS ARTHRITIS. 

and osteo-arthritis. By the former we mean that polyartic- 
ular jomt affection of the young adult which is characterized 
by spindle-shaped swellings of the joints affected, thickening 
of the joint capsule, and atrophy of the cartilage and bone. 
By osteo-arthritis we mean that polyarticular affection, usually 
of later adult life, characterized by hypertrophy and lipping 
of bone and cartilage, causing what is known as Heberden's 
nodes when the terminal phalanges are involved, and morbus 
cox£e sensilis when the hip is involved. Both of these diseases 
are accompanied by great villous hypertrophy of the ssmovial 
membrane, rheumatoid being much the more common. 

In several of the cases here reported this was the etiological 
factor; namely, Nos. 5, 8, 9, and 29. That osteo-arthritic 
joint involvement, due at times to a general diathetic condi- 
tion, but often wholly or in part to local trauma, may be a direct 
cause of villous hypertrophy, is illustrated by the following 
case (No. 7). The patient had a bony spur, evidently the 
direct result of an injury in football. This spur was surrounded 
by a villous hypertrophy. Removal of the spur and fringes 
certainly produced a complete cure twelve years after the 
original injury. 

Clinical History. — ^The joints most frequently affected with 
these forms of arthritis are the knee, the shoulder, the ankle, 
and the hip. Of these the knee is most frequently involved, 
probably on account of its exposed position, its function in 
the weight-bearing of the body, and the nature of its internal 
anatomy. Its exposed situation makes it liable to external 
trauma. Its function in the weight-bearing makes it liable 
to strain, and its internal mechanism is of a nature to be easily 
deranged. To a less degree these reasons apply to the other 
joints which have been mentioned. Depending upon the 
etiology of the arthritis in question, we find the type to be 
either monarticular or polyarticular. In cases following trauma, 
either direct or indirect, the lesion is monarticular, except 
where the etiological factor is bilateral in its distribution, 
such as pronation of the feet, relaxed knee-joint ligaments, etc. 

Of course, where the hypertrophy of viUi is due to toxic or 



C. F. PAmXER AND W. G. ERVING. 113 

inflammatory agents circulating in the blood, or to metabolic 
disturbances affecting the general processes of the body, one 
would expect to find a polyarthritis, and this is usually the case. 
In looking over the history of these cases, it is noticeable that 
a considerable period of time has passed since the beginning 
of the trouble. This is particularly true of the traumatic cases. 
In these an interval of years rather than months or weeks 
is the customary rule. The explanation of this is probably 
that, until fibrous changes of considerable extent take place 
in these fringes, they do not simulate foreign bodies as they 
do subsequent to such fibrous change. In the early stage 
of passive congestion they are soft, and are readily disposed 
of in the act of moving the joint, and so do not give rise to 
symptoms other than swelling and a certain amount of dis^ 
comfort and inconvenience upon first rising from a sitting posi- 
tion. Where some diathetic cause has been in operation, the 
fringe development has undoubtedly been so insidious that 
the patient cannot give a definite date to the onset of the 
joint symptoms. Here, then, we do not ordinarily find so 
long an interval between the onset of the trouble and the de- 
velopment of the joint fringes. In many cases there have 
been long intervals without symptoms referable to the joint. 
Such is usually the history where the primary cause was a trauma, 
giving rise to symptoms which were more or less temporary, 
with subsequent secondary traumata and lighting up of fresh 
symptoms. The symptomatology of this form of arthritis 
is often very indefinite, and readily accounts for the lack of 
attention hitherto paid to the condition. There is some- 
times an immediate onset of s]nnptoms directly associated 
with the trauma, but more usually the symptoms which are 
due to the fringe are distinctly different in the mind of the 
patient from those which resulted from the trauma itself. The 
symptoms which are directly referable then to the presence of 
the fringe are these: a more or less frequently recurring sjnio- 
vitis which perhaps never wholly disappears, a sensation of 
pinching something between the component bones of the 
joint in the act of walking, at first occurring rarely, but be- 



114 CHRONIC VILIiOUS ARniRITIS. 

coming progressively a more or less constant symptom dur- 
ing the use of the joint. There is also a more or less local 
swelling of the membrane of the joint, usually of that por- 
tion which is below the patella and on either side of the patellar 
tendon. Pain is not ordinarily present when the patient is 
quiet. Sometimes this radiates down the leg almost to the 
ankle, and is usually of a sharp incisive character. The normal 
passive motion of the joint is not interfered with in flexion, 
and only occasionally is extension somewhat limited. When 
this occurs, it is usually due to the hypertrophy of those few 
villi which arise from the alar ligaments. Locking of the joint 
almost never occurs, as it does in the case of the dislocated 
cartilages. Although the patient is conscious of the presence 
of a soft body between the articular surfaces, he is usually able 
to flex or extend the joint at will. What has just been said 
regarding the sjrmptomatology applies principally to the trau- 
matic cases. Those which are due to a definite arthritis of 
toxic or diathetic origin differ in that the swelling is more 
symmetrical, is rarely or never confined to any one quarter of 
the joint, is accompanied much less frequently by a true effu- 
sion. Where the hypertrophy of the synovial membrane is 
general, the joint often appears to be filled with fluid. The 
patella seems to float, fluctuation is easily obtainable, and one 
is frequently surprised on opening the joint to find no excess 
of fluid. Under these circumstances one finds a very large 
mass of soft pliable fringes, which protrude from the joint as 
soon as the capsule is opened. They look and feel in many 
cases like masses of small angle worms. In the cases depend- 
ent upon a general diathesis, as rheumatoid arthritis, contrac- 
ture of the joints, spasm of the muscles, and other evidences 
of a true arthritis are usually foimd. Such symptoms do not 
commonly accompany the villous hypertrophy due to trauma. 
Measurements made will show an increase in the size of the 
affected joints which, in cases of traumatic origin, is usually 
either below the patella or above the patella only. In the other 
types the swelling is more diffuse, and the enlargement of the 
joint is noticeable throughout its entire extent. Pain on 



C. F. PAINTER AND W. C. ERVING. 116 

motion of the joint is not commonly noted, except in the 
eases where there is a definite arthritis of diathetic origin. 
Tenderness, localized over the fringes which are most readily 
palpable, is not uncommon, and is, in fact, usually present 
where the fringe is of any considerable size. 

Differential Diagnosis, — In diagnosing this condition from 
others, few affections are to be considered. It cannot always 
be determined which of the several possible causes is respon- 
sible for the trouble. Usually, in the presence of any obvious 
joint disease, the explanation of existing fringes is not far to 
seek. Defects in the standing position of patients productive 
of joint strain at the knee should be looked for to explain 
symptoms such as have just been enumerated. The history 
of trauma should be inquired into. It has usually been suffi- 
ciently severe to attract attention. The general conditions 
occurring in weak and debilitated people which cause general 
and local muscular relaxation must also be borne in mind. 

With these general observations in mind, it remains to con- 
sider what other conditions may cause these symptoms. Early 
synovial tuberculosis must be considered. The patients' 
general condition in these cases is usually poor, as is also the 
case in rheumatoid arthritis. Tuberculosis, however, is mon- 
articular, while rheumatoid arthritis is polyarticular in a large 
majority of cases. It is in these early tubercular cases that 
explorations are indicated after other methods of diagnosis 
have been exhausted. 

The history of a gonorrheal affection accompanied by defi- 
nite joint involvements is suggestive, but a simple history 
of a gonorrhoea at some more or less remote period is of no sig- 
nificance. It also should be borne in mind that the infective 
arthritic processes are possible excitants to rheumatoid changes, 
and that such a history, with rheumatoid appearances in the 
joints on gross examination, may indicate the subacute or 
chronic state of an infective process, or the early stage of a 
rheumatoid. A histological examination would probably clear 
up such a diagnosis. 

A dislocated or partially dislocated semilunar cartilage 



116 CHRONIC VILLOUS ARIHRITIS. 

may cause confusion, and it is sometimes impossible to establish 
the diagnosis. As a rule, there is not the locking of the joint 
in a partially extended position in the villous hypertrophy, 
as there so frequently is in the case of the cartilage; and the 
history of the dislocated cartilage is suggestive. The diffi- 
culty arises where the cartilage was but slightly displaced, 
and was not accompanied by the customary trauma. In three 
cases in this series there were found hypertrophied s3movial 
fringes, evidently due to the derangement of the joint in con- 
sequence of a partially detached cartilage which had not been 
definitely diagnosed (Nos. 15 and 26). An habitually recurring 
synovitis will frequently be found to be due to the existence 
of a fringe or fringes. Any simple synovitis that cannot be 
explained away on some reasonable ground should cause suspi- 
cion. In this series is one case of intermittent hydrops that 
was full of well-developed fringes. The hydrops was not mate- 
rially benefited for any considerable length of time by the re- 
moval of the greater part of the fringes, so that this condition 
was probably simply a coincidence in the process. Intermittency 
in the accumulation of a synovitis would lead one to be rather 
less sanguine as to the probable benefit of an arthrotomy in 
a villous arthritis thus complicated, and should be borne in 
mind in the differential diagnosis. The cases in which ma- 
lignant disease, as sarcoma, finds its starting-point in the 
villi of a joint are so rare that they must be regarded in the 
light of medical curiosities. Of monarticular affections osteo- 
arthritis not uncommonly causes a villous arthritis. This is 
usually accomplished by the trauma inflicted upon the joint 
by the osteo-arthritic spurs, which develop about the con- 
dyles and along the border of the patella. These irritate the 
synovial membrane, and cause the development of fringes in 
their neighborhood. These spurs can usually be recognized 
on palpation and almost always in the skiagram. 

TreatmerU. — ^The treatment varies with the causation of the 
arthritis. Very many of the early cases, when caused by pro- 
nated or flat feet, where the condition in the knee joint is that 
of a passive hyperaemia due to the malposition, are promptly 



C. F. PAINTER AND W. G. ERVING. 117 

and permanently cured by resort to a proper support for the 
foot. This must be worn for a considerable time after the 
subsidence of the joint symptoms. Adhesive plaster strap- 
ping tightly applied over the front and sides of the knee to 
compress the synovial membrane and lessen the chance of its 
being crowded together and pinched by the action of the joint 
is helpful in relieving the s]nnptoms and causing the fringes 
in some cases to shrink up. This is particularly true in the 
cases where the condition results from general loss of tone 
in the joint capsule or from faulty attitudes in standing and 
walking. 

Where the villous hypertrophy is due to some diathesis, 
such treatment can be only palliative. In this last class of 
cases, however, the presence of the fringes is a source of irri- 
tation and injury to the joint, and here, as in all other cases, 
where strapping, bandaging, and correction of existing causa- 
tive defects in the feet are not effective, operative measures 
should be taken. Prolonged fixation in plaster or other splints 
does not accomplish any permanent good, and long-continued 
conservative treatment is not to be recommended. The fact 
that the individual and not simply the joint is being treated 
should not be lost sight of, and general tonic treatment, mas- 
sage, and exercises are indicated in the appropriate cases. 
In the osteo-arthritic cases, of course, any stirring up of the 
joints where spur formation is causing the villous hjrpertrophy 
is to be avoided. This applies to massage as well as to exer- 
cise, and here partial fixation in removable splints of leather 
is at times effective in quieting down the process. In such 
conditions as muscular and ligamentous laxity, some stages 
of the rheumatoid process, and the later or convalescent con- 
dition of the primarily infective cases, massage, exercise, and 
such measures are effective, and should be used. Here, also, 
local stimulating treatment by means of the alternate douche 
of hot and cold water is very beneficial. In the more acute 
stages of the rheumatoid fringes, hot fomentations and rubber 
dam worn next the skin at night give the patient more com- 
fort, although the nature of their therapeutic value is uncer- 
tain. Dry heat at high temperatures is of little value. 



118 CHRONIC VU.LOUS ARTHRITIS. 

The therapeutic treatment of the underlying condition in 
those cases, caused by rheumatoid and osteo arthritis, is most 
unsatisfactory. The acute rheumatic remedies should be 
used very sparingly and never continuously. -The same is 
true of the sedatives and soporifics. Careful nursing, fixa- 
tion of the affected joints during the acute stage, and gen- 
eral tonic treatment give the best results in the long run. Diet 
should be plain, but plentiful, and restricted only by the pa- 
tient's capacity for digestion. These details are gone into here 
for two reasons. Many practitioners who have overlooked the 
fringes, because they have not examined their patient's joints, 
regard the symptoms arising from these conditions as rheu- 
matic, and treat them accordingly. The result is that the 
patient's general health becomes undermined, and if, per- 
chance, the villous arthritis is rheimiatoid in character, the 
worst consequences are to be expected. .On the other hand, 
rational therapeutics has its place, and should be thoroughly 
followed. 

Operative Treatment. — ^Failing in the relief of these condi- 
tions by the before-mentioned conservative measures, we 
have to consider the radical or operative procedm^. These 
are to be undertaken when other treatment has been tried 
and failed, or when the condition is such as obviously could 
not be relieved by conservative methods. It offers the quick- 
est and, in the long run, the most satisfactory results. It is not 
attended by any particular risk, and is rational in every way, 
especially in the cases of traumatic origin. Under the modem 
technique one thinks very little of the risks of infection. In 
this series of cases this has not occurred. With proper after- 
treatment there is no serious probability of a stiff joint, and 
restoration to normal motion and complete function is usually 
speedy and uncomplicated. There is practically no risk of 
weakening the joint because of the incision through its fibrous 
envelope, and there have been, so far as observed, no late seque- 
lae which tend to make one hesitate to operate. Where the 
villous arthritis is simply an evidence of a chronic general dis- 
ease, the purpose of the operation differs from that in the cases 



C. F. PAINTER AND W. G. EKVING. 119 

in which the hypertrophied villi are the result of an injury 
or of some acute inflammatory process. To reach these fringes 
in the knee joint, which is the joint most commonly explored, 
it has been found that a lateral incision about 5 to 6 centimetres 
long over the inner aspect of the joint, extending a short distance 
below its lower border, affords an opportunity to investigate 
a considerable portion of the synovial membrane by direct 
inspection, and what cannot be seen can be explored by the 
finger. Familiarity with the ''feel'' of the fringes makes one 
quite expert in detecting them where they cannot be seen. 
If in this way it is demonstrable, or presimiable even, that 
more fringes are situated on the outer side of the joint, a simi- 
lar incision is to be recommended over that aspect. In ex- 
treme cases, usually due to some diathesis, where there is 
extensive hypertrophy of the villi, we think that it is reasonable 
and proper to connect the two incisions which are usually 
made for exploratory purposes at their lower extremities, and 
in doing this to divide the patellar tendon close to its insertion 
into the lower border of the patella. On turning back the 
flap, the entire joint cavity is exposed, and the dissection of 
the vilU is much more easily accomplished. The objection to 
this procedure is that the convalescence is necessarily pro- 
longed because of the six weeks or more of immobilization 
of the knee required after division and suture of the patellar 
tendon. In several cases where joint tuberculosis has been 
diagnosed early, excision of the parts of the synovial membrane 
attacked by the disease has been attempted, and this incision 
has given admirable opportunity for the removal of the disease, 
while the functional results have been extremely good. This, 
too, in spite of the fact that it was necessary, because of the 
nature of the disease, to protract the convalescent treatment 
very materially. 

The removal of these villi is not ordinarily accompanied 
by any recurrence because the cicatrization of the denuded 
portion of the capsular surface causes the entire membrane 
to shrink, and scar tissue does not readily lend itself to villous 
hypertrophy. Thus, even in the diathetic cases, where the 



!») CHRONIC VILLOUS ARTHRITIS. 

removal of the fringes is performed for the sake of freeing 
the joint from their irritative action, good results may be ex- 
pected both locally and generally, through the improved func- 
tion of the joint and the consequent influence which this im- 
proved function has upon the general condition of the patient. 

Sometimes, on account of the vascularity of these fringes, 
some diflBiculty is experienced in checking the hemorrhage. 
It is impossible to ligate all the small bleeding vessels inside 
the joint, and the cauterizing effect of hot water is necessary. 
The only bad result attributable to our technique which has 
occurred in this series of cases was one in which the water 
supplied was so hot that the synovial membrane was scalded, 
and sloughing took place. This case is still under treatment, 
and we are trying to secure motion in the joint with apparently 
satisfactory results. 

The capsule is closed with interrupted silk sutures, usually 
four or five in niunber, placed some distance apart, so as not 
to close too completely the synovial capsule. They also in- 
clude the fibrous tissue. The skin incision is closed with 
either interrupted silkworm gut or subcutaneous continuous 
silver. In the majority of cases silkworm gut was used. 
In regard to dressings we have had experience both with fixa- 
tion and with soft dressings alone. All our early cases were 
put up first in plaster of Paris dressings, which were kept on 
for at least a week. 

In several recent cases immobilization was not practised, 
a soft dressing only being used. Joint eflFusion was no more 
marked, the patient suffered no increase in discomfort, and 
motion was apparently obtained more quickly in these cases. 

Poslroperative Treatment, — ^The post-operative treatment is 
fully as important as any which has preceded it. Unless 
there are indications to the contrary, dressings are not dis- 
turbed for one week, at which time the stitches are removed, 
and passive manipulation is begun at once. 

The cases vary considerably with respect to early restric- 
tion of motion, and they seem to vary directly in proportion 
to the size of the bases of the pedicles from which the fringes 



C. F. PAINTER AND W. G. ERVING. 121 

depend. In other words, the more vascular the pedicle which 
connects the villus with the general sjoiovial membrane, the 
more extensive is the denuded surface after the fringe has been 
excised, and, where there are a number of these broad denuded 
areas, adhesion seems to be more likely to occur. These ad- 
hesions, however, are very slight, and are readily overcome 
in most patients without an anaesthetic, and, when this is nec- 
essary, but one, or at most two, manipulations under gas are 
required. 

Passive manipulation by the patient and active manipu- 
lation by the physician should be practised daily during the 
second week. At the end of this time motion is usually re- 
stored to ninety or more degrees. It is then safe to allow the 
patient to begin to bear weight on the leg, and to encourage 
him to walk, supported somewhat by a crutch or cane and 
wearing a compression bandage, such as is made from Shaker's 
flannel. Daily hot and cold douching stimulates the joint, 
and facilitates its restoration to normal functional activity. 

Some soreness and stiffness persists often for a longer period 
than this, but, ordinarily, at the end of the second or third 
week the active treatment of the joint should be practically 
completed. Subsequent visits are usually unnecessary. 

Paihology. — The appearance of these hypertrophied joint 
fringes ranges within wide limits. The smaller are of a red- 
dish-gray to purplish color, of delicate dendritic appearance, 
attached to the synovial lining of the joint by an extremely 
slender and delicate pedicle, and are present in great numbers, 
presenting a fungus-like appearance over the entire membrane. 
Their consistency is very soft and yielding, and their vascular- 
ity is especially marked. 

In the other extreme are the large, irregular, coarsely lobu- 
lated, yellowish fatty masses of 4-5 cm. in diameter, often glued 
by constant inflammation to the synovial lining over a wide 
area, though the original pedicle is generally to be distinguished. 
These are usually but one or two in number, and occupy the 
greater part of the joint cavity. More rare are the fatty masses 
without any trace on inspection or palpation of fibrous tis- 



122 CHRONIC VILLOUS ARTHRITIS. 

sue, and the masses of hyaline necrotic tissue or of connective 
tissue infiltrated with bone or cartilage cells. Between these 
limits are all shapes and sizes, the pedunculated appearance 
and rich supply of vessels being the most common character- 
istics. 

On section, the tissue even in the larger growths is very rarely 
of a true fatty consistency. There is always a resistance 




FiQ. 1. Arborescent lipoma. Actual size. 

characteristic of the presence of fibrous tissue in some amoimt, 
which in a few instances passes into the gritty solid resistance 
of bone and cartilage. 

A microscopic examination of the smaller* growths shows 
the pedicle to be composed of niunerous parallel blood ves- 
sels imbedded in a mass of small round-celled tissue, with a 
thin endothelial lining. Following this to the enlarged bul- 
bous end, the periphery of the growth is found to have the 
same nature. The cortical portion is composed of an endo- 
thelial lining, consisting of a single layer of cells, and a con- 
nective tissue groundwork infiltrated with the small round cells 
characteristic of a chronic inflammatory process, often arranged 
in definite whorls, somewhat resembling a tubercle. But these 
whorls never contain the characteristic round epithelioid 
cells, the giant cells, or the necrotic areas, characteristic of 

•VideF\g.6. 



C. p. PAINTER AND W. G. EllVING. 



123 



tuberculosis. Minute blood vessels are very numerous. A 
short distance from the outer border of the fringe, fibrous 




Fio -I. Section of Fig. i. 




^' 



Fiu. 3. Normal lipoma for comparison with Fit^.2. 

tissue begins to predominate over the small round cells, and 
this shortly gives way to adipose tissue of normal appearance. 



124 CHRONIC VILLOUS ARTHRITIS. 

which constitutes the remainder of the growth. This is not 
pure adipose tissue, however, for at intervals appear strise 
and irregular collections of more or less normal connective 
tissue, usually associated with the vessels. Although usu- 
ally these bands are definite and stain deeply, yet often they 
stain but feebly, and show evidence of granular necrosis. The 
vessels, very numerous throughout, show, especially in the 




Fio. 4. Shows typical fringe formation, marked round- 
celled infiltration at the tip, with fatty hase. 

central portions, marked endarteritic changes, and, where the 
adipose tissue is most abundant, the vessels are very small, and 
their lumina are very frequently obliterated. 

These same appearances hold true even in the largest fatty 
growths, save that in these cases the peripheral layer of small 
round cells is much thinner and at times almost entirely ab- 
sent, while the areas of unbroken fatty tissue tend to increase 
in extent. Occasionally, and in apparently very chronic 
cases, the specimen shows a mass of unbroken fatty cells, with 
no patent blood vessels, though occasionally traces of their 
walls which have undergone hyaline necrosis are to be distin- 
guished. Here, too, are found irregular patches of former 



C. V. PAINTER AND W. G. ERVING. 126 

fibrous tissue which have become hyaline, — ^a condition which 
is universal throughout the fringe in rare cases of many years' 
standing. 

Bone and cartilage cells were found in but one case, but here 
they formed definite areas of large size. In no case are any 
signs of tuberculosis apparent, nor is there any tendency to 
the formation of malignant new growths, though instances 




Fifs. 5. Shows islands of cartilage and bone developed 
in a synovial fringe. 

of the fonner are plentiful and of the latter not unknown in 
the literature. 

Prognosis, — The question of the prognosis in these cases 
cannot, we think, be definitely spoken of as yet because of 
insufficient data on the subject. It must be borne in mind 
also that, in giving a prognosis, account must be taken of the 
cause of the villous hypertrophy. The operation cannot be 
justly condemned as a surgical procedure because a latent 
general disease has been overlooked by the operator. In the 
traumatic cases, and those due to faulty weight-bearing, there 
is every reason to look for a good result, provided, of course, 
that in the latter case the defective mechanics are corrected. 



126 CHRONIC VILLOl^S ARTHRITIS. 

Neither is it fair to expect or to lead the patient to expect a 
cure of rheumatoid arthritis to follow the simple removal of 
large masses of fringes from the knee joints. In this and 
allied diseases causing villous arthritis the most that can be 
held out by way of encouragement to the patient is the hope 
that, by improving the function of a large joint whose integ- 
rity istvitally concerned in promoting the individual's general 
welfare, the individual may put himself in a position the better 
to overcome the diathesis. In many cases this can be accom- 




Fi<}. G. l^nifituduial section through a frinflre. sliowing 
the vascularity, fatty centre and infiltrated border. 

plishod, in others it cannot. So far as the cases here reported 
can afford any basis for a prognosis, bearing the beforp-men- 
tioned circumstances in mind, and remembering the compara- 
tively short time which has elapsed since the date of opera- 
tion on the first of the series, it seems fair to claim that in the 
traumatic cases the prognosis is very good, whereas in the 
diathetic cases it is impossible to obtain very brilliant results. 
The long standing cases are apt to suffer from a condition of 
marked joint relaxation, which requires some after treatment 
tending to the strengthening of the muscles and shrinking 
up of the capsule; and this takes time. In one of our cases, 
where the fringes had developed directly beneath the patellar 



C. F. PAINTER AND W. G. ERVING. 127 

tendon, they had attained such size as to crowd the tendon 
forward and prevent its coming perfectly straight in exten- 
sion of the leg. This patient has had some difficulty in recov- 
ering complete voluntary extension, apparently because of this 
elongation of the patellar tendon. Abbott, in a recent arti- 
cle, speaks of a paralysis of the quadriceps extensor which 
has not been observed in our cases. 

Conclusions. — 1. Chronic villous arthritis is not a disease 
of itself, as has been claimed by some authors. It occurs as- 
sociated with chronic diathetic disease which involves other 
tissues than the synovial membrane of the joints affected, 
but it is representative in such cases of the same pathologic- 
al changes which subsequently obtain in the other structures 
of the joint. The two principal diatheses which cause this 
are rheumatoid arthritis and osteo-arthritis. The villous 
changes in these two chronic conditions are to be regarded 
as symptoms of a general condition, and not as an entity in 
themselves. 

2. Traumatism, entirely apart from any diathesis, is capable 
of giving rise to an hypertrophy of villi, and this hypertrophy 
is usually a local one in the part of the membrane directly or 
indirectly injured. The type commonly goes on to a dense 
fibrous growth, which keeps the joint in a constant state of 
injury through its traumatic effects. 

Traumatism, associated with an osteo-arthritic diathesis, 
is frequently the excitant of local synovial hypertrophy; but 
the synovial changes are apparently more the result of the 
trauma than of the stirring up of the diathesis. 

3. Stout, flabby adults, with pronated or flat feet, are more 
liable to the type of fringe which undergoes fatty degeneration 
with a minimimi amount of fibrous change. This condition 
is sometimes associated with pregnancy, the tissue relaxations 
of nervous prostration, and the "soft'' condition of so many 
rapidly growing and sickly children at the period of puberty. 

4. Alteration in the mechanics of weight-bearing is not, 
as has been recently stated, the prime cause of this condition 
in many of the knee cases. It is very frequently a contribut- 



128 CHRONIC VILLOUS ARTHRITIS. 

ing factor, and as such should be given its full weight when 
questions of treatment arise; but it is extremely doubtful 
if simple flat foot or pronated foot without some more funda- 
mental tissue change can account for this condition. 

5. The operative treatment in the property selected cases 
gives eminently satisfactory results when undertaken with 
an understanding as to what the procedure contemplates. 
Conservative treatment, when carried out properly in suitable 
cases, which comprise, however, only a small class, gives equally 
good results. The main thing is to be able to discriminate 
between the classes. 

6. Judging from the pathological findings, the condition is the 
result of a chronic inflammatory process of whatever cause, 
which, by acting upon the normal villi of the synovial mem- 
brane, causes their hypertrophy, together with a consequent 
great increase in the number of their blood vessels. This con- 
dition becoming chronic, due to the continuance of the toxic 
cause or to intermittent and slight trauma, the vessels are 
unable to supply the needs of the new tissue, affected as they 
are themselves by the inflammatory process. 

The result is their gradual endarteritic obliteration with 
the almost complete loss of blood supply and the disappear- 
ance of the normal fibrous tissue, which either undergoes 
necrosis and hyaline degeneration, or disappears, leaving in 
its place tissues which can be nourished by a very limited 
supply of blood, the adipose being the most common form. In 
this necrotic condition, separation of the pedicle and the forma- 
tion of a loose joint body can easily occur. 

HinLIOOHAPIIY. 

1. Abbott, E. (;., Jour. Amer. Medical Assoc, 1903. 40—1131. 

2. Harwell, H., Internat. Cycl. of Surgery, 1884-4. 

8. Bazy, Bulletin de la Soc. Anatoni. de Paris, 1890. Ser. 5, Vol. 4. 
4. Billroth, Allg. Chirur. Pathol, und Therapie, 1888. 817. 
o. Blachian, Deutsche Zeitschrift fur Chir., 1893. 36 — o75. 

6. Bolton, N.Y. Medical Jour., 189(}. 03—830. 

7. Boyer, Bulletin de la Soc. Anatom. de Paris, 1877. Ser. 4, Vol. 
2, 129. 



C. F. PAINTER AND W. G. ERVINO. 1» 

8. Goplin, Manual of Ftithology, 242 and 685. 

9. Danzel, Deutsche Zeitschr. fUr Ghir., 1879. 11—599. 

10. Delafield & Prudden, Pathology, 817 and 779. 

11. Dor, Gazette MMical de Paris, 1898. Ser. 2, Vol. 8, 556. 

12. Godlee, Transact, of Pathol. Society of London, 1881. 32—207. 

13. Goldthwait, Boston Med. and Snig. Journal, 1900. 143—12. 

14. Gotz, Dissert Inaug. zu Halle, 1798 (quoted). 

15. Hagen-Tom, O., Archly fur Mikroskop-anat., 1882. 21—591. 

16. Halstead, A. E., Transact, of Chicago Pathol. Sodetj, 1896. 
1—207. 

17. Hanmann, Inaug. Dissert., fionn, 1887 (quoted). 

18. Hektoen-Riesmann, American text-book of Pathology. 

19. Eonig, Gentralblatt fiir Chiruig., 1886. 25. 

20. Lauenstein, Gentralblatt fur Ghiruig., 1884. 11—836. 

21. Le Bee, Le Franc. M^., Paris, 1893. 40—4. 

22. Modlinski, Medizinskoje Obojrenije, 1891. 20 (quoted). 

23. Miiller, Joh., Ueber den feinem Bau und die Formen der Krank- 
haften-Geschwiilste, Berlin, 1838 (quoted). 

24. Painter & Erving, Boston Med. and Surg. Jour., 1903. 148—305. 

25. Patterson, Glasgow Med. and Suig. Jour., 1879. 11—66. 

26. Patterson, Journal of Anat and Physiol., 1890. 24. 

27. Biedel, Deutsche Zeitschr. fiir Chiruig., 1878. 10—37. 

28. Biedel, Archiv fiir klinisch. Chiruig., 1891. 41. 

29. Biedel, Archiv fiir kluusch. Ghirurg., 1893. 45. 

30. Bobson, A. W. Mayo, Lancet, 1891. 1—934. 

31. Shattock, S. G., Lancet, 1888. 1—775. 

32. Schmolk, Deutsche Zeitschr. fiir Chiruig., 1886. 23—283. 

33. SchiiUer, Archiv fur klinisch. Chiruig., 1893. 45. 

34. Schuller, Berlin, klinisch. Wochenschr., 1900. 37—93, etc. 

35. S6e, Bull, et M^moires de la Soc. de Chir. de Paris, 1882. N. 6. 
8-457. 

36. Simon, G., Langenbeck's Archiv, 1893. 6—573. 

37. Sokoloff , Chirurgitscheski Westnik, 1893. 2 and 3 (quoted). 

38. Sokoloff, Yolkmann's Klin. Yortrage, 1893. N. F. 81. 

39. Solly, Trans. Path. Soc. of London, 1848. 2—111. 

40. Stieda, Beitrag fur klin. Chiruig., 1896. 16. 

41. Sutton, J. Bland, Trans, of Path. Soc. of London, 1888. 39—290. 

42. Yibiac, Jour, de M6d. de Bordeaux, 1894. 23—275. 

43. Yolkmann, Billroth, & Pitha, Handbuch der Chiruig., 1865. 
2—576. 

44. Yolkmann, Beitrage fur Chiruig. Jahresbericht der TJniven. 
Klinick zu Halle, 1873. 183 (quoted). 

45. Weir, B. F., N.Y. Med. Jour., 1886. 29—725. 

46. Ziegler, Lehrbuch der allg. Pathol. 2—220. 



II. 

A TREATMENT OF OSTEITIS DEFORMANS AND 
OSTEO-ARTHRITIS. 

F. E. PECKHAM, PROVIDENCE, R.I. 

In recent times many attempts have been made to increase 
the knowledge of osteitis deformans and osteo-arthritis. These 
studies have mostly dealt with the pathology, and more recently 
the physiology, of these diseases; but it will be observed that all 
writers have had Uttle or nothing to ofifer in the way of treat- 
ment. I wish to oflFer the following cases simply for the appar- 
ently favorable results of treatment: — 

Case 1. — ^W. H. Overseer in a mill. Three years ago he first 
noticed a slight lameness and stiffness of the left leg and knee. 
During the first three years he had this trouble constantly, being 
somewhat better in hot weather and worse on exposure to cold. 
He had been treated for rheumatism about a year without results. 

Physical Examirwiion. — Well nourished and developed. Heart 
and lungs negative. The left hip is slightly sensitive to pressure, 
and there seems to be some thickening about the joint. There 
is good motion in flexion and rotation. There is an atrophy of 
1\ inches in the left thigh. There is also ^ inch shortening, 
lliere is marked resistance and limitation to hyper-extension. 

In order to clear up the diagnosis, if possible, 4 milligrams of 
tuberculin were injected April 18, 1901, with no reaction. On 
April 22 6 milligrams were injected. Again no reaction. At 
tins time the diagnosis was fairly certain of an osteo-arthritis or 
beginning osteitis deformans, and the following treatment was 
b^un. The skin about the hip and down the thigh was super- 
ficially cauterized every month. In the middle of the month 
a small blister about 1 by 2 inches was produced in the lumbar 
region, on the side of the spine corresponding to the diseased 
hip. This treatment was continued at these regular intervals 
for about a year. When he first came under my care, he was in 
bed, but I allowed him to return to his work in the mill at the 
very beginning of treatment. Here he was on his feet con- 
tinually every day. Improvement began with the very first 

Pxesented at the Seyenteenth Annual Meeting of the Aasooiation. Waahington, 
D.C.. May il-M, 1903. 



F. E. PECKHAM. 181 

treatment, and continued uninterruptedly until the end of the 
year. He could then walk with perfect comfort, and there was 
absolutely no pain. It is now about a year since the cessation 
of treatment, and there have been no return of symptoms, and 
tibe disease has not attacked the other hip or any part of the 
body. 

Case 2. — ^A man of about fifty years of age. Occupation, clerk 
and book-keeper. This man has always been perfectly healthy. 
His occupation has kept him on his feet most of the time, and 
he has been in the habit of taking long walks Simday, twelve or 
fifteen miles. Twelve years ago he strained the left knee in 
playing ball, and he thinks the leg has never been quite straight 
since. In 1898 he had inflammation of the periosteum below the 
knee, which lasted for two or three months, and was followed 
by perfect recovery. His attention was called to his present 
condition by his friends, who told him he was walking lame. For 
three or four weeks before coming for advice he had complained 
of pain, mostly in the hip, and sometimes slight twinges of pain 
up and down the leg. 

Physical Examination. — ^There was some thickening around 
the trochanter, and the leg measured i inch shorter than its 
mate, due to the curvature of the femur. An X-ray plate re- 
vealed a tjrpical osteitis deformans. 

First treatment was July 20, 1902, when the skin about the 
hip and down the thigh was superficially cauterized in many 
places. August 7. — ^Pain much relieved after first treatment. 
He now walks five and six miles Sundays with comfort, which 
he had formerly been imable to do. In the middle of each 
month the spine was blistered, as before described. October 
15. — ^Has been on a himting trip for three or four weeks, and 
has been on his feet as much as any of the party. He walked 
twenty-five miles in two days, and the pain has practically dis- 
appeared. Feb. 23, 1903. — He is in excellent condition, there 
are no symptoms, the disease has not attacked any other joints, 
and at present (May, 1903) remains apparently cured. 

Case 3. — C. F. I. Age, forty-two years. Has been a motor- 
man for the past four years. He came to me first Jime 25, 1902, 
saying he had never been sick at all until Feb. 4, 1902, when 
the knee was somewhat painful. This lasted for about a month, 
during which time he was not laid up, and the recovery was per- 
fect. He then went to work on the car for two days, when in 
March he suddenly fell in the street with excruciating pain in 
the hip and thigh. He was laid up in bed for two weeks, and 
has been imable to work since. 



182 OSTEITIS DEFORMANS AND OSTEO-ARTHRITIS. 

Physical Examination. — ^The man walked into my office with 
great difficulty, iising a crutch and a cane. At every step a dis- 
tinctly audible squeak was noticed. There was motion in flex- 
ion of 45-50^, and on manipulation this same squeaking could both 
be felt and heard. Rotation was one-half. Every motion caused 
discomfort, and considerable muscular rigidity was present. The 
right leg was ^ inch shorter than its mate, due to the curved 
femur. An X-ray plate showed the presence of a tjrpical osteitis 
deformans. The hip and thigh were superficially cauterized, 
and the spine was to be blistered between treatments, as usual. 
July 25. — ^Patient reports himself somewhat improved, and no- 
tices that the squeaking is less and the muscular rigidity dimin- 
ishing. September 22. — ^Has been on his feet quite a little, work- 
ing in a garden, getting about very comfortably with a cane. 
A slow improvement continues. Oct. 27, 1902. — ^At this time, 
four months only from the first treatment, he is a great deal 
better, and for the last two weeks has been at his customary 
work (motorman) nine-elevenths of a day. A slight squeaking 
still remains. May, 1903. — Is working every day, and the 
disease is apparently quiescent. 

Case 4. — R. R. Male, age thirtynseven years. In 1898 he 
was troubled with renal colic, and first complained of pain in 
knees. This gradually grew worse, until he could not get his 
legs into a comfortable position at night. In 1900 a bowing of 
the legs began, which has gradually increased imtil the condition 
is one of well-marked bow-legs. During the summer of 1902 he 
had night sweats, and, when first consulting me, he weighed one 
himdred and thirty-five poimds, which was seventeen pounds 
less than three years previous. Also at this time he was suffer- 
ing severe pain, and had to cross his legs in order to get to 
sleep. An X-ray plate showed an osteitis deformans. Aug. 16, 
1902. — ^Both hips and legs down to the knee superficially cau- 
terized, and patient instructed to blister spine, as before de- 
scribed. Sept. 21, 1902. — ^Has had only one bad day since the 
first treatment, and on September 20 says he walked two 
(2) miles in the country, which he could not have done any time 
during the last two months. Although here was improvement, 
and as much as in any of the cases after only one treatment, yet 
he never reported again, and, when I met him on the street some 
time afterward, he said the treatment was too harsh, and that 
the discomfort from the cauterization kept him awake for three 
or four nights; and he never came back for further treatment. 

Of osteo-arthritis without involving the shaft of the long bones 
there is one case: — 



F. E. PECKHAM. 133 

Case 1. — Osteo-arihritis of the right shoulder in a man of fifty 
years of age. This trouble began with pain and stiffness of the 
shoulder, being worse at night. The disease increased in severity, 
until he was unable to lie down in bed, but was compelled to sleep 
sitting up. This had been going on for about six months, until 
when he first consulted me, Sept. 1, 1901, the arm was held 
rigidly by muscular spasm, and the slightest motion caused ex- 
cruciating pain. The disease was apparently rapidly progress- 
ing, and was a case of sleepless nights spent in a chair and extreme 
piun all day. Sept. 1, 1901. — ^The skin all about the shoulder 
was superficially cauterized, and this was repeated at monthly 
intervals, while midway between these treatments a small blister 
was applied just to the right of spine at the lower end of cervical 
r^on. These applications were continued at regular intervals 
for a little less than a year. Improvement was immediate from 
the very first treatment, and continued steadily imtil he con- 
sidered himself well. At first he could scarcely move the arm 
at all, and then only with great pain, while at the end of treat- 
ment there was no pain at all. The motion is now free in all 
directions except elevation above a right angle with the body. 
Here the bone thickening apparently interferes. 

I realize that only a few cases are reported, but the results are 
surprising enough to warrant a continuance of the treatment 
in similar cases. 

DISCUSSION. 

Dr. GoLDTHWAiT Said that it was a well-known fact that any counter- 
irritation over the seat of the active process was followed by relief, and . 
that also there were periods of quiescence in the disease which might last 
several years, and then the disease become active again. He had had one 
case in ^diich an incision had been made by another physician before the 
patient had come to him. This gave great relief, but did not of course 
permanently check the disease. He did not think any counter-irritation 
would materiaUy change the course of the disease. Probably all the 
members had seen cases as striking as those reported, in which the patient 
had been crippled, and in which it had been possible by strapping or some 
other line of treatment to enable the patient to work. With regard to 
the case of supposed osteo-arthritis of the hip he could not help question- 
ing the diagnosis. There was no limitation of rotation, and the other 
motions were free. In osteo-arthritis of such long standing, rotation would 
be mechanically impossible. Possibly the case was one of peri-arthritis 
or of ilio-psoas biirsa. He was inclined to accept the latter view. The 



134 OSTEITIS DEFORMANS AND OSTEO-ARTHRITIS. 

description of the shoulder case presented a very dear picture. In the 
active stage of osteo-arthritis the disease attacked the anterior part of the 
humerus at the point of attachment of the anterior portion of the capsule 
of the joint, and anything which caused hyper-«xtension of the shoulder, 
such as occurred diuing sleep, gave rise to pain. He recalled one very 
striking case in which the patient was taking a grain of morphine at night, 
and yet by simply putting a pillow under the elbow, and preventing the 
drag upon the anterior ligament, he was enabled to sleep all night without 
morphia. Counter-irritation or an3rthing which increased the circulation 
at this point would relieve the symptoms without question. Oauterixa- 
tion, blistering, hot water, or anything else which tended to increase the 
circulation, gave relief, provided it did not cause irritation of the part 
actually diseased. For this reason massage aggravated the condition by 
causing irritation. 

Dr. PocKHAii said that, if the case had been one of ilio-femoral bursa 
of such long standing, it would not have been cured spontaneously in that 
way. He had another case of osteitis deformans occurring in a physician, 
a patient seen by Dr. Goldthwait. Early in the history of that case the 
man had an X-ray bum over the anterior surface of the thigh or in the 
groin. The t3rpe of the disease was very mild, and he thought this was 
another example of the process having been greatly limited by the irrita- 
tion. 



Ill, 

OBSERVATIONS ON HIP DISEASE AS SEEN AMONG 
HOSPITAL OUT-PATIENTS. 

AUGUSTUS THORNDIKE, M.D. 

The following study was undertaken for the purpose of finding 
out what the treatment in vogue at the Children's Hosfntal in 
Boston has been accomplishing for hip disease. In a measure 
it was designed to show up shortcomingSi and to pave the way 
for better care of patients. 

In order to obtain end results, all cases of undoubted hip dis- 
ease, which came to our clinic at the hospital ten years ago as 
new patients and remained long imder treatment, were selected; 
but, as the number was small, those presenting themselves nine 
and eleven years ago have been added. No other selection has 
been made. 

The conditions which prevail in the out-patient department 
of any hospital in a large city are by no means ideal: many prac- 
tical difficulties exist which are to be mitigated, but cannot be 
entirely removed. 

Children of the social class who are there imder treatment in 
their homes with a mechanical appliance or splint, suffer from: 
(1) lack of care in properly applying the apparatus; (2) from 
broken splints, broken straps and buckles; (3) they come for 
inspection irregularly and often at long intervals; (4) many come 
from a distance, and seldom can afford the expense of the journey; 
(5) it is difficult to instruct some parents in the proper use of 
apparatus, either on accoimt of ignorance and stupidity or 
because of their inability to understand English; (6) the slow 
course of the disease causes dissatisfaction, and leads to with- 
drawal from the clinic, and, occasionally, to a return after the 
effect of a year's or more disregard of the malady has left its in- 
delible mark. It is not surprising, then, that the results are less 
good than in private practice: rather astonishing is it that all 

Presented at the Seventeenth Annual Meeting of the ABBodation. Waahincton, 
D.Cm ICay ii'ii, tMA. 



196 mP DISEASE AMONG HOSPITAL OUT-PATIENTS. 

parents do not become disgusted because treatment is so pro- 
longed. 

In examining these cases, which nimiber 55, we find them 
equally divided as to sex; that in 17 the disease was in the right 
hip, 36, left, and 2 on both sides; that the children were from edx 
months to twelve years old when they first pasne for treatment, 
owing to the rule of the hospital, which treats children under 
twelve years of age. 

Affe. Number, Per cent. 

Less than 1 year 2 3.7 

I to 2 years 2 3.7 

2to 8 " 5 9.2 

8to 4 " 9 16.6 

4to 6 " 10 18.6 

"ilJ 

r 

5 to 6 yean 8 15. 

6 to 7 " 6 11. 

7 to 8 « 2 3.7 

8 to 9 « 3 6.6 

9 to 10 " 4 7.4 

42!6 

10 to 11 yean 2 3.7 

II to 12 " 1 1.8 

Total ~5i Ti 



There were 2 children less than a year old; 2 between the 
ages of one and two years; 5, from two to three; 9, from three 
to four; 10, from four to five; 8, from five to six; 6, from six to 
seven; 2, from seven to eight; 3, from eight to nine; 4, from nine 
to ten; 2, from ten to eleven; 1, from eleven to twelve; and 1 
whose age was not recorded. 

From two to seven seems to be the favorite age to develop hip 
disease, and babies of a few months do not escape. 

The time which elapsed between the detection of early sjrmp- 
toms by the parent and the first visit to the hospital was noted 
in all but 2 cases: less than a month in 4, one month in 6, two in 
9, three in 3, four in 8, five months in 2, six in 7, seven in 1, nine 
in 1, ten in 2, one year or over in 5. Or, to state it a little differ- 



AUGUSl'US THORNDIKE. 137 

enUy, 10 said they had had it a month or lesSi 19, two months, 
or less; while only 5 out of the 53 came after a year had elapsed, 
and they had been imder treatment in other places. 

This is interesting, as it shows that the widenspread effect of 
the teaching of orthopedics both in Boston and throughout New 
England has led to early recognition and early care of hip dis- 
ease. Twenty-five years ago many would limp aroimd for years 
untreated: some undoubtedly still do so, but their number is 
being reduced. Early treatment offers so much more chance of 
preventing deformity that it is important for both the profession 
and the laity to realize the necessity of bringing all lame children 
without delay under surveillance and treatment. 

In trying to make an estimate of the duration of the malady 
in these cases, the number of available records becomes much 
smaller in consequence of going back ten years. Many leave the 
clinic, and fail to answer inquiries because they do not get well 
quickly; others, because they pass the age limit, and are trans- 
ferred to other climes still wearing their splints. I have esti- 
mated the duration from the time the parents noticed the first 
sjrmptoms until the apparatus was successfully discarded (by 
successfully is meant without any ill effects for a year or more 
afterward). 

Of the 17 cases, 1 successfully left off apparatus after eighteen 
months (a baby treated on the posterior wire or Cabot frame), 

1 at four years, 1 at four and a hsdf , 1 at five, 1 at five and a half, 

2 at six and a half, 2 at seven, 1 at seven and a half, 2 at nine, 
1 at nine and a half, 3 at ten, and 1 at ten and a half years. 

If we except the baby, who did not walk imtil the splint was 
abandoned, the shortest duration was four years, and the long- 
est still wears a convalescent splint after eleven years. 9 out of 
the 17 left the splint off after a period varying between six and 
a half and ten years. There has been trouble in abandoning the 
use of splints. After some relapses or exacerbations, attributed 
to discarding apparatus too early, the splints are now left off 
very gradually, at first for an hour a day, increasing one hour 
a week; and during the whole of this period, and for two months 
after, they are obliged to report weekly for observation, and, 



138 HIP DISEASE AMONG HOSPITAL OUT-PATIENTS. 

if any muscular spasm arises, they are told to wear the splint 
six months more, and to let us see how they are then. 

Under this strict rule, splints are at times worn longer than 
they need be, in the hope of avoiding relapses. 

The treatment employed has varied but slightly. Different 
forms of splints have been used, some cases have been treated 
without traction; but most of them used some modification of 
the Taylor long-traction splint. 

Prolonged recumbency never was employed in these cases, but 
recumbency on the Bradford frame with weight and pulley trac- 
tion was used for 35 out of the 55 (63f per cent.) for periods 
varying from a week to eight. It was done either in the ward 
or at home imder the supervision of the trained nurse sent from 
the hospital; 11 children underwent periods of recumbency 
twice, and 4 three times, for correction of faulty position of the 
hip or for the relief of the acute sensitive hip. For apparatus 
the Taylor long-traction splint, with a few simple modifications, 
was used on 49 of the 55 cases, and a long convalescent spUnt 
followed on most of them. The plaster of Paris spica was used 
on only 3 of these cases: all 3 happened to do badly. It is much 
more frequently employed to-day. One of these was given a long- 
traction splint, and is still wearing his convalescent splint. Of 
the others, 1 left the clinic a year later, and is still acutely sensi- 
tive: the other was reported by letter to be very lame. 

The Cabot frame was used for little babies three times with 
good results. 1 of the double hip cases had a double long-traction 
splint, which was changed to a double Thomas hip splint with 
benefit. The other case still wears the double Taylor splint. 

The proportion of cases which had abscesses was two-fifths 
(42 per cent.), or 23 children. 2 nature reabsorbed. The 
other 21 (38 per cent.) were incised, curetted, and drained in 
the Children's Hospital, excepting 1 at the West End Infants' 
Hospital. The proportion of tubercular sinuses following oper- 
ation for drainage was large, and they persisted many months. 
Necrosis of the acetabulum was detected twice by operation in 
these 21 cases of abscess: there were also 2 cases of excision of 
the hip, in both of which the pelvis was found diseased. Many 



AUGUSTUS THORNDIKE. 



199 



of those with abscess had previously been in the ward for traction 
in bed to correct faulty position or to allay the sensitive hip, but 
4 of the abscess cases had not. 

The proportion of cases with abscess indicates that this group 
of hip cases belong to the severer type of hip disease. 

The amount of permanent deformity and real shortening was 
investigated. 



SHORTENING AND RSSULT. 



Shortening. 


Number. 







X inch 




)i " 




JC " 




1 « 




lu inches 




IH " 




1^ u 




2 " 




i)i " 




3 


2 


4 


3 


4X " 


1 



35 



Ayerage, 1>^ inches. 

60 per cent had 1 inch or less. 

83 per cent had 2 inches or less. 



Per cent, 
20. 

2.8 
17. 

8.6 
11.4 

2.8 
11.4 

6.7 

2.8 

2.8 

5.6 

8.4 

2.8 



Out of 36 cases 7 had no shortening; 1, \ inch; 6, } inch 3, | 
inch; 4, 1} inches; 2, 1| inches; 1, 2 inches; 1, 2^ inches; 2, 3 
inches; 3, 4 inches; and 1, 4^ inches, — average, 1^ inches. 

All of the cases with 3 or more inches of shortening showed 
something imusual to have produced it. 1 with 3 inches of 
shortening had the trochanter 2 inches above N^laton's luxe, and 
ankylosis after ten years of hip disease. 

Another had imdergone subtrochanteric osteotomy; in 2, ne- 
crosed bone had been removed from the acetabulum; and 1 
had imdei^gone excision of the hip. 

Permanent flexion of the hip was studied in 43 cases: a few 
degrees of permanent flexion were foimd in 5 cases; 10^ in 7, 20P 
in 7, 30^ in 3, 45^ in 3, and more than 45^ in 2 cases. 16 cases 
showed no permanent flexion present. 



140 HIP DISEASE AMONG HOSPITAL OUT-PATIENTS. 

As much as 20^ of permanent flexion may exist without im- 
pairment of the gait: 20^ or less was found in 35 out of 43, or 
about 81 per cent. Better results would have been obtained, had 
more attention been given by the parents to traction and proper 
care of apparatus. It is certainly true that permanent deformity 
can be prevented by careful and persistent mechanico-therapeu- 
tic treatment at least nine times out of ten. 

Of the bad results 1 was ankylosed with 30^ of permanent 
adduction, and 2 had a persistent adduction of 10^ without bony 
ankylosis. 

The final results as to joint motion in flexion was for 45 cases: — 

Motionless 14 

Less than 20<' 9 

20 to 46 8 

46tof0 4 

90 and over 10 

Total 46 

In other words, 22 had more than 20^ of motion, and 23 less: 
about one-quarter had motion to the right angle or beyond. 
Motion in abduction: — 

Abduction was impossible in 14 

possible up to 16** in 8 

good in 6 

almost normal in 8 

Total number 30 

In estimating these final results, several cases who did not 
respond to letters were included, taking the measurements from 
the record book, if they had been coming at least six years when 
the last measurements were made. The figures show that, even 
with poor home care, in an out-patient clinic considerable move- 
ment and control of the joint may frequently result. Certainly 
more than half enjoy a free walking gait; but it is to be remem- 
bered that the selection of these cases was made at a distance of 
ten years, and they represent only those who remained the longest 
under treatment. They, therefore, by selection belong to the 
graver cases of hip disease. 

On attempting to compare these results with those published 



AUGUSTUS THORNDIKE. 141 

by Gibney, Waterman, and Reynolds five years ago, from the 
clinic of the Hospital for Ruptured and Crippled in New York, 
one notices that their figures were obtauxed from patients five 
years or more after they had been discharged from the hospital 
presumedly well. About a tenth had returned, and were again 
under treatment. These statistics included also the severer types 
of hip disease. We find that in Gibney's cases 66 per cent, 
showed 1 inch or less of actual shortening, and 86 per cent. 2 
inches or less: in the Children's Hospital, Boston, we find 60 
per cent, with 1 inch or less, and 83 per cent, with 2 inches or 
less. So that the figures correspond in a rough way, and are 
slightly to the disadvantage of the Boston clinic. 

As regards motion, the balance is the other way: 22 per cent, 
of the Boston cases could flex to a right angle, 9 per cent, to a 
point between 45® and the right angle, 17 per cent, to a point be- 
tween 20® and 45®, 20 per cent, from a few degrees to 20®, and 31 
per cent, were fixed and without motion. The fact that about 
one-eighth of these cases were still imder treatment makes it 
undesirable to institute the comparison, for it is the rule that 
the amount of motion present when apparatus is discarded de- 
creases for a few years. 

In Konig's recent work on Bones and Jouxte, 568 cases of hip 
disease from the Royal Berlin Hospital clinic were analyzed. 
Abscess occurred in two-thirds, or 66 p^ cent. There were 381 
resections of the joint. If these excisions be omitted, the pro- 
portion of cases having abscesses becomes one-sixth instead of 
two-thirds, showing that resection is more frequently done in 
Berlin for suppuration than here. Konig evidently favors ex- 
cision where American orthopedists would treat conservatively, 
and he undoubtedly saves time. "Resections," he sajrs, "were 
formerly too frequent; but now we are too apt to neglect the 
operation in favor of conservative treatment." We believe that 
with earlier and more careful orthopedic treatment the number 
of cases requiring resection may be greatly lessened. One reason 
for the greater amoimt of suppuration in Berlin may arise from 
failure to recognize hip disease early, or to enforce efficient trac- 
tion or fixation early in the course of the disease. 



142 HIP DISEASE AMONG HOSFITAL OUT-PATIENTS. 

Such have been the end results in these cases, who after a kmg 
period of splint treatment, varying from four to ten years, have 
been walking without apparatus for a year or more without any 
return of acute sjrmptoms. A fair proportion would not be no- 
ticed to limp: others are less fortunate. None are deprived of 
walking, and almost all walk well if their real and apparent 
shortening be compensated for with a high heel or sole. Future 
improvement in the end results is expected from greater and 
constant attention to all the Uttle details of treatment, from 
more nourishing food, plenty of out-of-door air and sunshine, 
and from careful skiagraphic study of lesions which often yields 
new indications for treatment, if only we can learn to correctly 
interpret them. 



IV. 

HIP DISEASE, CONSIDERED WITH SPECIAL REFER- 
ENCE TO DIAGNOSIS AND THE COMBINED 
TREATMENT. 

Second Paper. 

R. TUNSTALL TAYLOR, M.D. 

In the paper which I presented laat year to this Association, 
under the title of "The Combined Treatment of Coxalgia," mean- 
ing thereby both the mechanical and operative treatment, I ad- 
vocated the anterior incision, erasion, disinfection by 2J per cent, 
formalin solution, of the tuberculous focus and suture in that 
middle class of cases in which the X-ray and clinical sjonptoms 
showed conclusively that the mechanical means alone did not 
tend to arrest the extension of the process and prevent destruc- 
tion of the articulation. I followed up the operative treatment 
with the bed and ambulatory mechanical treatment ordinarily 
employed. I used pure carbolic acid and alcohol after erasion 
in a number of cases, but lost 1 from carbolic acid poisioning, 
so that now I use formalin as the safer antiseptic. 

I did not advocate the operative treatment in the earliest 
stages of extra-articular tuberculous foci at the coxo-femoral 
articulation, for the reason that the mechanical treatment will 
often cure such cases; nor did I recommend operative inter- 
ference on tuberculous foci, where discharging sinuses (inva- 
riably secondarily infected) were present, for obvious aseptic 
reasons. 

However, in the 9 operative cases presented I reported 3 with 
sinuses discharging, on which all other means had failed to re- 
lieve the acute symptoms of pain, night cries, etc., 3 in which 
there was very extensive bone destruction, and in which from 
the low state of the patient's health one would readily infer 
abscesses with sinuses would form^ and 3 in which the disease 

PreMnted At the Seyenteenth Annual Meeting of the Aaeoclatlon. Waehinflrton, 
D.C., May U-14, 1908. 



144 HIP DISEASE. 

was advancing, as shown by the X-ray; but one could only sur- 
mise that extensive caseation and suppuration would occur if 
unchecked. 

I dwelt at some length on the skiagraphic diagnosis, which is 
so readily and promptly obtained in coxalgia in children within 
an hour or two, how perfectly evident the nature of the lesion 
is, the characteristic clouding and softening seen even in very 
early stages, locatmg exactly the portion of the joint involved, 
and not giving rise to the questions which must needs arise with 
tuberculin, when used for diagnostic purposes. We now find 
it necessary to employ the latter only in exceptionally difficult 
cases. With a family history of tuberculosis, an insidious onset, 
muscular spasm, limitation of motion, even if only present at 
the limits of motion, night cries, atrophy, a slight elevation of 
temperature, malposition of the limb in attitude and gait, and 
the X-ray negative, tuberculin becomes superfluous, except in 
very rare instances, and this applies not only to the hip, but to 
the other joints and spine, so that we may now place tuberculin 
among the '' Ancient and Honorables," to be used only in difficult 
cases in conjunction with the X-ray. 

The fflmplicity of the tuberculin test appeals to one at first, if 
we may disregard the discomfort of the patient and the '' increased 
local reaction" (which last, however, is as often absent and no 
guide). To an observer, who has pretty well made up his mind 
that a case is or is not tuberculous, the local reaction in joint 
disease readily lends itself to his point of view, just as any one 
similarly impressed would get a range of motion of so many de- 
grees, while another observer would find a dissimilar range hold- 
ing opposite views. 

According to C. M. Wood's analysis of 100 cases in which 
tuberculin was used at the Cook Coimty Hospital for Consump- 
tives (Journal American Medical Association, April 19, 1902), 
he f oimd that with doses as large as ten to fifteen milligrams that 
a positive reaction miLst consist of a rise of temperature of 2^ 
within six to thirty-six hours, together with at least two of the 
following symptoms: nausea, chilUness, headache, and muscular 
pains. How rarely we find two of these symptoms associated 



R. TUNSTALL TAYLOR. 145 

in tuberculous children with the fever reaction, and simply find 
the lassitude and anorexia incident to the fever! 

The sjrphilitic, leprous, and neurotic have been reported time 
and again as responding to the tuberculin injection, giving a 
positive reaction; and Wood states, to use his words, that "in 
something less than 50 per cent, of cases syphilis gives a reaction 
which can hardly be distinguished from that of tuberculosis. 
Consequently, in any case showing a reaction, active syphilis 
should be excluded before it is decided that the case is tuber- 
culous." Syphilis and tuberculosis are among the most common 
causes of joint disease. May we not be delaying a long time in 
making our diagnosis, while anti-syphilitic therapy is being em- 
ployed for exclusion, before pronouncing the case tuberculous? 

Actinomycosis is said to react also. In an infant in my wards 
a few years ago, with swelling below the trochanters, slight 
fever, lessened function, pain cauang insommia, but without 
muscle spasm and with joint motion, a prominent consultant, 
after repeated increasing doses of tuberculin and no action, was 
inclined to blame the tuberculin (Trudeau's) for a non-tuber- 
culous diagnosis; for he considered it at first a '' low form of bone 
tuberculosis," but later suggested ''sarcoma." So that with 
negative reaction we are often perplexed. The X-ray showed 
periosteal thickening, the joint intact; and mercury cured the 
ease. 

From my experience with the two methods nmning over a 
period of some years, I should be led to advise and value the 
X-ray first in the diagnosis of bone and joint tuberculous, if good 
negatives are obtainable, and recommend tuberculin (rrily when 
either good negatives cannot be obtained or cannot be inter- 
preted or are inconclusive, with the skiagraph and ssrmptoms. 

Our custom has been to use from 3 to 5 milligrams of tuber- 
culin obtwied from Koch's or Trudeau's laboratories, made up 
freshly with zi of distilled sterile water, mi? of a 5 per cent, car- 
bolic solution, and mj of tuberculin. 1 minim of this solu- 
tion is equivalent to 1 milligram of tuberculin. For less than 
5 milligrams we use a more dilute solution for acciutusy. 

The more detail one obtains in the skiagraphs, either in devel- 



146 HIP DISEASE. 

opment or by inteDsification of the negatives, and the more ex- 
perience one has in the interpretation of X-rays, the plainer the 
pathological lesion becomes. 

In order to form some idea of the value of the combined treat- 
ment, if one can do so from the 9 cases reported, I will now com- 
pare their present condition with that which obtained before the 
operation, and for convenience will divide them into three groups, 
as indicated above. 

I. In the group in which the disease was shown by the X-ray 
and symptoms to be advancing, but in which one could only 
surmise that extensive caseation and suppuration would occur 
if imchecked, we have cases 2, 3, and 5. 

Case 2.— M. D. Died on the operating table as a result of 
carbolic acid poisoning, and hence gives us no information in 
the treatment of these cases except the danger of the use of pure 
carbolic acid in the joints. 

Case 3. — L. R. Girl, age seven years. First seen November 
28, 1901. Duration of di^ase before operation, three and one- 
half years. Right hip. Duration of treatment elsewhere, one 
year (plaster spica and bed traction). Hospital for Crippled 
and Deformed Children, one year, bed traction and brace. Gen- 
eral health good. Joint fimction before operation, no motion. 
Position of limb: flexed 15^ adducted 6®. Thigh atrophy, ^ 
inch. Shortening: real, f inch; apparent, J inch. X-ray diowed 
caseated areas in upper surface of head and neck. Operation, 
February 19, 1902. Foci of granular debris in upper surface of 
head and neck removed by curettes. Pure carbolic poured in 
cavity. Status prassens: General health excellent. Joint func- 
tion: flexion, 80®; abduction, 5®; adduction, 10**. Rotation: 
out, 45**; in, 0**. Brace removed December 15, 1902. Position 
of limb, adducted 6**. Thigh atrophy, 1 inch. Shortening: real, 
\ inch; apparent, 1 inch. Walks with slight limp, and can sit 
comfortably erect. 

Case 5.— R. W. L. Boy, age four. April 24, 1899. Dura- 
tion of disease before operation, three and one-half years. Left 
hip. General health: pale, wan, listless, only fairly nourished 
and color poor; anorexia and constipation. Joint function be- 
fore operation: flexion, 30**; abduction, 10°; adduction, 5**. Ro- 
tation out, 90**; rotation in, 5**. Position of limb, adducted 6®. 
Thigh atrophy, li inches. Shortening, apparent, i inch. X-ray 
showed thickened joint, disintegration of femoral head. Oper- 



R. TUNSTALL TAYLOll. 147 

ation, March 27, 1902. Gritty bone detritus removed, including 
a large piece of the femoral head and upper part of neck. One 
ounce of pus evacuated from capsule. Pure carbolic acid and 
alcohol used. Brace removed January 15, 1903, and allowed 
to walk. Status prcBsens: General health excellent. Joint 
fimction: flexion, 5**; abduction, 10**; adduction 10**. Rotation 
out, QP; in, 6**. Position normal. Thigh atrophy, i inch. 
Shortening: real, none; apparent, none. He walks quite well, 
but cannot flex thigh in sitting. 

In these two cases I feel the result is better than it would have 
been if mechanical treatment alone had been used. Sinuses 
would probably have formed, and the dmation of the disease 
has been unquestionably shortened; for the patients have no 
mechanical treatment now, and only massage is employed. 

Even granting the small range of motion in Case 5, the absence 
of shortening and the excellent position of the limb promise 
greater usefulness than would have been obtained, considering 
the pathological destruction present, had the operation not been 
done and traction not been made in abduction. The progress 
of the disease was imdoubtedly stopped, and healing obtained 
at once. 

II. The next three cases form a group in which, from the low 
state of the patients' health and the very extensive and mcreas- 
ing destruction, one would most certainly expect abscesses to 
form, with sinuses to further sap their already depleted systems. 

Case 4.— I. W. Girl, age four. First seen July 28, 1901. 
Duration of disease before operation, thirteen months. Child 
had no vitality; was very frail, anaemic, and thin. Joint fimc- 
tion, no motion in right hip. Position of limb, flexed 30** and 
adducted 10**. Atrophy of thigh, J inch. Shortening: real, 
none; apparent, \ inch. X-ray showed involvement of whole 
head and neck down to intertrochanteric line. Operation, May 
7, 1902. At the operation nothing but gritty remains of the 
r^t femoral head was found, and the cartilaginous portion of 
the head was loose within the capsule, as a shred, perhaps 1^ 
inches long and } inch wide. At least two tablespoonfuls of 
tuberculous bone was removed, and formalin was used. 

In my paper of last year I stated that " the present indica- 
tions are that the child will not have a stiflF joint; but how much 



148 HIP DISEASE. 

motion she will ultimately have, or whether there will be a re- 
lapse, it is impossible to say: how stable her joint will be is also 
problematical." 

Stattts free-sens: Child looks exceedingly well, has a good color 
and is fairly nomished. Joint function: flexion, 85^; abduction, 
45**; adduction, 30*". Rotation: out, 90*"; in, 20**. Position of 
limb normal. Joint stable. Atrophy of thigh, f inch. Short- 
ening, real, ^ inch. Lengthening, apparent, ^ inch. Brace re- 
moved April 25, 1903. Walks as one would from the lack of 
' use of a limb, and can sit erect. An altogether unexpected and 
gratif3ring result. 

Case 1. — M. E. W. Girl, aged eight years. First seen Octo- 
ber 10, 1901. Duration of disease before operation, six months. 
Right hip. Child was thin, delicate, and ill-looking. Night 
cries and pain distressing. Joint function, nil. Position of 
limb: flexed 50**, adducted 10°. Atrophy, i inch. Real short- 
ening, none. Skiagraph showed general clouding of the joint 
and erosion of upper surface of femoral head and neck. Epi- 
physes of trochanters cannot be seen. Operation, February 26, 
1902. Perhaps half an ounce of dead bone removed from upper 
and anterior surface of the femoral head and neck, as is well 
shown in skiagraph taken after operation. Status prcesens. 
General condition very good, and she is better nourished. Joint 
fimction: flexion, 60°; adduction, 10°; abduction, 10°. Rotation: 
out, 60°; in, 0°. Position of limb, 4° adducted. Atrophy, thigh, 
2 inches. Shortening: real, 1 inch; apparent, 1^ inches. Brace 
removed April 15, 1903. Leg is very weak. Cannot walk well 
yet, but can sit erect comfortably, and outlook is excellent. This 
case has turned out also better than could be hoped for ordi- 
narily. 

Case 7. — F. H. Boy, age five years. First seen January 31, 
1900. Duration of disease before operation, four years. Left hip. 
Thin and tuberculous-looking lad. Joint function: flexion, 30°; 
abduction, 10°; adduction, 0°. Rotation: in, 5°. Position of 
limb, fixed at 90° outward rotation. Atrophy of thigh, 1 inch. 
Shortening: real, ^ inch: apparent, none. Skiagraph showed 
destruction of a great deal of tissue in head, neck, and acetabu- 
lum. November, 1900, operation through posterior incision 
(not advised ordinarily) chosen on account of large abscess form- 
ing. Joint curetted as thoroughly as possible through this in- 
cision, 1:200 bichloride irrigation used, and wound left open. 
Healed by granulation. Traction stopped June, 1902. Status 
prcesens: General health excellent. Joint function: flexion, 5°; 
abduction, 5°. Position of limb, 4° adducted. Atrophy, thigh, 



R. TUNSTALL TAYLOR. 149 

2^ inches. Shortening: real, ^ inch; apparent, 1 inch. Only 
walks fairly well, and sits awkwardly. This case having been 
operated on through the posterior incision, when a sinus and 
abscess were forming rapidly and allowed to granulate up, is 
scarcely a fair type of what can be accomplished early by the 
method advocated (viz., the anterior incision). 

III. The third is the septic group in which sinuses had formed, 
and the patients were laboring with a mixed infection at the 
time when the operation was done, as all other means did not 
relieve the acute symptoms. 

Case 6. — ^T. C. Boy, aged eight years. First seen August 
21, 1900. Duration of disease before operation, four years. Boy 
thin, amemic, and general condition poor. Periodic attacks of 
pain and hectic fever. Joint flexed in adduction 6°. Two pro- 
fusely discharging sinuses. X-ray shows extensive disease of 
head, neck, and acetabulum. Joint practically obliterated. 
Bones atrophied. Thorough curetting of head, neck, acetabu- 
limi, capsule, and sinuses. Pure carbolic and alcohol used. 
March 1, 1903, traction splint and bed night traction discon- 
tinued. Crutches alone used. Status prcBsens: General condition 
and health excellent. One sinus closed: the other discharges 
about z] of pus a day, but this is lessening. No pain nor acute 
symptoms. Shortening: real, i inch; apparent, J inch. 

Case 8. — J. S. Boy, aged five years. First seen February 
20, 1901. Dm-ation of cOsease before operation, 20 months. 
Left hip. Condition very poor, thigh riddled with sinuses. 
X-ray showed worm-eaten head, neck, and acetabulum. No 
motion. Position of flexion, 60®. Position of adduction, 5**. 
Thigh atrophy, J inch. Shortening: real, J inch; apparent, J 
inch. Erasion done December 27, 1901, by external incision, 
to avoid sinuses, which were widely opened, irrigated with 1 : 2000 
bichloride, healed by granulation. Traction discontinued May 
1, 1903. General condition good. Apparent lengthening, ^ 
inch; actual lengthening, i inch. Position of flexion, 5*^; posi- 
tion of abduction, 15®. No motion in flexion, abduction, or ad- 
duction. Sinus discharges about 3/s5 per week. 

Case 9. — ^W. E. Boy, aged four years. First seen July 12, 
1899. Right hip. Duration of disease before operation, four 
years. Condition similar to Case 8. No motion; malposition, 
in flexed position, 60®. X-ray showed separation of a portion 
of the acetabulum and a pimched out erosion of the femoral 



160 HIP DISEASE. 

head and its separation. Erasion, February 5, 1902; ext^nal 
incision; healed by granulation of wound; bicholoride disinfec- 
tion. Status prcesens: General condition good. Shortening: 
real, ^ inch; apparent, none. Position of flexion, 5^. Motion: 
flexion, 20®; abduction, 5**; adduction, 5*^. Rotation: out, 90®; 
in, 30®. Slight discharge from sinus. Traction discontinued 
May 1, 1903. 

The last three cases simply go to prove the importance of 
checking the extension of the tuberculous process before joint 
disintegration occurs. The X-ray is a valuable guide, if skiar 
graphs are made from time to time, which is our evident duty 
in all cases of hip diseases, to note any extension of the process; 
and the combined treatment is imperatively indicated from my 
experience to cut short the disease, and manifestly demanded 
if the mechanical treatment alone will not arrest it. 

I will not trespass further on the time and patience of the Asso- 
ciation by reporting similar cases operated on during the past 
year; but I will state that my research in this direction has re- 
paid me according to my judgment, and I have used, and will 
use, the combined treatment on every case in which the skiagraph 
shows extending caseation, until I have conclusive proof of my 
error. Of the two contra-indications suggested, suppuration 
and metastasis of the tubercle, I have experienced no examples. 
In regard to the third contra-indication, — ^viz., shortening of 
the limb in the t3rpical cases at the time when the operation was 
indicated, — the maximum real shortening is 1 inch (1 case) of 
the 5 suitable cases, if we include very extensive joint destruc- 
tion in the suitable cases. Of the other 7 cases, 2 had i inch real 
shortening, 4 had ^ inch real shortening, and 1 had no shorten- 
ing, more than a year after the operation. 

3 of the 5 cases, in which good joint fimction might possibly 
be hoped for, have excellent free motion (Cases 1, 3, 4). In 
Cases 5 and 7 we have practically ankylosis in a normal useful 
position, but these 2 cases had run three and one-half and four 
years before the operation respectively. I do not doubt that 
Case 4 would have siu^ly had sinuses; and, if amyloid disease 
did not cause her death, ankylosis would have been the result. 
As it is, partial regeneration seems to have taken place. 



R. TUNSTALL TAYLOR. 151 

The erasion and dismfection has undoubtedly benefited the 
septic cases also, not only in general health, but in the condition 
of the joint. I feel no one will question that the course of the 
disease is shortened by the operation. 

Is this procedure to be recommended as a routine method of 
treatment? 

My experience, although covering but a few cases, perhaps 
some 20 in all, would lead me to think most favorably of it, and, 
as I have said, lead me to adopt it, until I have conclusive proof 
of my error; and I therefore reconmiend it, and trust that others 
may report their experiences with it. 

In regard to the after-treatment: — 

Our cases are kept in bed some eight to twelve weeks after the 
operation with traction in abduction. They are then gotten up 
with the long-traction splint bent also in abduction. This they 
wear for six months; and, if all goes well, then they discard the 
high shoe, crutches, and walk on the convalescent splint attached 
to shoe without traction. At the end of the year they are al- 
lowed to go without apparatus, and have massage, passive and 
then active gymnastics, to increase the power of abducting the 
limb. 

To return to the question of diagnosis for a moment. Vulpius 
claims that many so-called prompt cures of coxalgia are in reality 
eases of mild osteomyelitis, due to pyogenic bacteria and not the 
bacillus tuberculosis. To refute this, should we not only make 
the cultures in the ordinary way at the time of the operation or 
exploratory incision, and not only do this, but inoculate guinea 
pigs with the open joint scrapings? 

Lorenz has criticised our prolonged use of traction as detri- 
mental. 

Is he right about this (although we all recognize his aims at 
ankylods, as the desideratum in tubercular hip disease, fall far 
short of ours for motion) 7 I am inclined to think he is, if I can 
judge by my own experience and observation. Have we not all 
seen bad cases of genu recurvatum and an unstable limb as the 
result of too prolonged traction treatment for coxalgia, espe- 
cially with that type of traction splint without posterior oalf 
and lower thigh bands? 



152 HIP DISEASE. 

After the acute stage of the disease is passed, could we not 
sooner discard the traction splint for some partial fixation or 
convalescent apparatus to allow moderate functional use? 

We have all seen, in skiagraphs especially of paralytic and 
congenitally dislocated shoulders, how the humeral epiphysis 
and diaphysis on the unused side is infinitely smaller and less 
developed than its mate. Is not the lack of functional use and 
lessened circulation more largely to blame for this than the tropic 
centres or the disease? If the epiphysis is underdeveloped, so 
must the limb be proportionately shortened. We have all no- 
ticed neglected contracted legs from infantile paralysis, and what 
extreme shortening there is in those cases in which the leg has 
not been straightened and braced to allow functional use at an 
early date, and how much less the shortening is when the logs 
can be used early. Does not this teach us to allow functional 
use in coxalgia as early as is safe, and not keep up the traction 
too long? 

Finally, will the X-ray not help us to determine the proper 
time to allow functional use of a tuberculous joint tentatively? 

One of the most striking features which one sees in the X-ray 
negative in the earliest or late stages of active tuberculous ar- 
thritis or epiphysitis is the clouding, which is present for some 
distance around the foci, while all the details on the normal side 
are sharply defined. The trochanteric epiphyses cannot be seen 
in the negative on the diseased side; and the worm-eaten appear- 
ance in the joint, if the process has gone that far, is seen through 
a haze. 

After operation, or as healing takes place, the outlines of the 
various parts become more and more sharply defined, until there 
is practically no difference in the detail observable on the two 
sides. 

Thus the X-ray from the beginning until the end of this dis- 
ease is one of our most valuable guides. 



V. 

SOME POINTS IN THE TREATMENT OF HIP-JOINT 

DISEASE. 

GEORGE B. PACKARD, M.D., OF DENVER. 

I wish only to discuss very briefly in this paper two or three 
points in the treatment of coxitis. 

In the various voliunes of om* Transactions the subject of the 
treatment of hip-joint disease has been very thoroughly dis- 
cussed. Not only the relative merits of excision, fixation, and 
traction have been thoroughly gone into, but the value of the 
various splints and their modifications in producing the desired 
ends. I believe that it makes very little difference whether we 
use a Thomas splint, a long-traction splint with a good fitting 
hip band, or other modifications, provided the appliance is ac- 
curately adjusted and the patient properly observed. 

In nearly all cases the disease yields to any of these methods 
of treatment (so far as acute symptoms are concerned), espe- 
cially if they are instituted early, although the ultimate result 
may be attended with a varjdng amount of deformity. But, 
whichever method we use, we expect in a short time that the 
spasm will diminish, the pain, if present, cease, and the power 
improve. 

One of the questions that confronts the writer after the relief 
of the acute or apparently active symptoms is. How long should 
this treatment be continued without allowing some functional 
use of the affected member? 

Dr. Henry Ling Taylor, in a paper read before this Associa- 
tion on ''The Retardation of Growth as a Cause of Shortening 
after Coxitis," arrives at the following conclusion: — 

The amount of retardation of growth appears to bear a dis- 
tinct relation to the amoimt and duration of the restraint or 
disability. 

My attention was very forcibly called to the relation that the 

Presented at the Seye&teeth Annii»l Meeting of the ABsoolAtion, Washinflrton, 
D.C^ May n-M, 1M3. 



IM TOEATMEN T OF HTP-JOINT DS3BASB. 

lack of functional use bears to retardation of growth and dis- 
ability following coxitis by the following case: — 

A girl of fourteen years was admitted to St. Luke's Hospital, 
Denver, and came under my care. She had recovered from 
double hip-joint disease, with marked adduction of both legs and 
flexion of the rights The legs were crossed with bony ankylosis 
at the left hip, but with some moti(xi remaining in the right. 
There was no displacement of the head of the bone from the 
acetabulum on either side, neither did suppuration occur in 
either joint. There was marked muscular atrophy above and 
below the knee of the right, and 2 inches of actual shortening 
as compared with the left. I performed subtrochanteric osteot- 
omy on the left femur and tenotomy of the adductors of the right 
side, and brought both legs into good positions. I found later 
that the right leg was not only Shorter and the muscles atrophied, 
but the power very much reduced. On account of the flexion 
of the right femur she was imable to make much use of the right 
leg in locomotion. While bending forward, she could reach the 
floor with the toes, but it remained pendent most of the time. 
She bore her weight upon the left leg with the assistance of a 
crutch as soon as the pain, tenderness, and disability were re- 
lieved, which was about one year. The mechanical treatment 
was of short duration, inefficient, and only applied to the right 
leg. She had been walking with a crutch for about five years. 

It will be observed that the right leg which she brought into 
constant use, on account of position, directly after the subsidence 
of the acute sjrmptoms, is a strong, well-developed member, with 
bony ankylosis, while the left,* which has been practically at rest 
from its flexed position and deprived of functional use, is atro- 
phied, short, and weak, although considerable motion is pre- 
served. 

We have here two tuberculous joints where many of the ele- 
ments we have to consider in these cases are identical. The 
early symptoms, environment, and general condition are the 
same. The only difference in the management of the joints was 
that one was brought into use comparatively early, while the 
other remained more nearly at rest for a long period. 



GEORGE B. PACKARD. IftS 

This case seems to illustrate the importance of a certain amount 
of functional use as early as practicable, and perhaps to corrob- 
orate the correctness of a principle laid down by Professor 
Lorenz in the treatment of tuberculous disease of joints in chil- 
dren. He advocates weight-bearing after the subsidence of pain 
and tendemess; but continues to immobilize the joint for a long 
time, and aims to procure bony ankyloos in a good position. 
I have never allowed complete weight-bearing as early as he 
suggests, but have used a protective brace that removes the 
greater portion of joint pressure, but permits use of muscles and 
some motion, if it does not increase the spasm. 

It may be said, in criticism of the position taken in this paper 
by the writer, that a recurrence of active symptoms is likely to 
occur if complete fixation and protection is discontinued soon 
after the subsidence of active symptoms. It is true a relapse 
will take place in a certain number of cases, but a relapse will 
also take place many times when immobilization and protection 
have been kept up for several years. And, when we come to 
consider the likelihood of retarded growth and the weakness 
that is likely to follow a long-continued lack of function, would 
it not be more rational to substitute massage of the muscles and 
a protected use of the joint after the subsidence of the active 
symptoms? — the latter usually extending from a few months to 
a year, and in some cases longer. In fact, my first instructions 
on the management of the treatment of coxitis by the late Dr. 
Charles Fayette Taylor were in accordance with these princi- 
ples. If I remember correctly, his plan was to use a long-traction 
splint for several months, or until the acute symptonis were re- 
lieved, particularly until the spasm of the joint was diminished, 
and then to substitute a brace with motion at the knee that pro- 
tected the hip joint, but allowed a certain amount of functional 
use. If he found that the spasm increased from this change, 
he returned for a while to the original treatment. 

While I gradually abandoned this plan of treatment for pro- 
longed fixation and disuse, I have during the last few years re- 
turned to it with some modification, and feel that in the end it 
gives the best functional results. 



156 TREATMENT OF HIP-JOINT DISEASE. 

Another point that I wish briefly to consider is the importance 
of the hygienic and constitutional treatment. I believe these 
measm'es exert a powerful influence in the control of this disease. 
I fully agree with the sentiments expressed by our fellow-member, 
Dr. Galloway, in his paper on this subject at the last meeting of 
this Association. The general treatment has undoubtedly been 
neglected in our enthusiasm over the methods for local treatment. 

We should also remember the liability of these cases to develop 
pulmonary tuberculosis at any time, This would be a serious 
complication, and it is an important reason for placing these 
cases under the most favorable conditions possible. The more 
favorable the surroundings, the less likely are active symptoms 
or suppuration to develop. We all know the influence of sim- 
shine, fresh air, and increased nutrition on puhnonary tuber- 
culosis. The effect on joint tuberculosis is equally beneficial. 

Relapses take place many times, or dissemination of tubercle , 
with development of tuberculosis in other organs, without regard 
to the time the joint has been immobilized. Therefore, it be-, 
comes a serious question if we have done our duty in trjring to 
overcome this inherited tendency or weakness which favors the 
development of the specific organism. Many sniffer from non- 
hygienic surroxmdings. We should urge that as much tune as 
possible be spent in the open air and sunshine, and when indoors 
the time should be spent in well-ventilated rooms, and at night 
sleep with open windows, regardless of the temperature. The 
diet is also an important factor in the treatment of these cases. 
Children particularly are very careless about taking the proper 
amount of food, and, xmless this matter is looked after very care- 
fully, they will not take the proper amount of nutrition. While 
no absolute rule can be given for diet on account of the idiosjm- 
crasies and complications, yet in a general way it may be said 
that meat, fats, raw eggs, and milk should be taken freely. I 
think an excellent plan in these cases as well as in other forms 
of tuberculosis is to take three substantial meals a day, each meal 
to be followed in a short time by a glass of milk and a raw egg, the 
latter not taking the place of the regular meal, but simply sup- 
plementing it. Gastric disturbance will not occur as often from 



GEORGE B. PACKARD. 167 

this method of increased feeding as it will when the extra food 
is taken midway between meals. 

When ansemia is present in addition, we must be persistent 
with the use of haemoglobin or iron and arsenic. I feel confi- 
dent that, if the general rules observed in the treatment of pul- 
monary tuberculosis as regards hygiene, diet, and general 
management were applied to joint tuberculosis, we should be 
able in a measure to overcome the inherited or acquired weak- 
ness that favors the development of the specific organism and 
its subsequent effect upon the joint. If we work along these 
lines a little more, I believe it will not be found necessary or ad- 
visable to continue so long our restrictive measure to the joint, 
but will permit of earlier fimctional use, and thereby prevent a 
good deal of the retarded growth and weakness that are so fre- 
quently observed. 

These remarks are not intended as the slightest reflection on 
the great importance of local treatment in coxitis, but are simply 
suggested as adjimcts in obtaining the desired ends. These sug- 
gestions apply equally to other tuberculous joints, but I used 
the hip joint as an illustration as being perhaps a joint where 
the disease is more serious and where treatment is continued 
longer, and where we are more likely to get retarded growth and 
weakness. Perhaps my cases are observed under more favorable 
conditions than the average on accoxmt of the favorable climatic 
condition of the Rocky Mountain region, and consequently there 
might be less danger in withdrawing active local treatment com- 
paratively early. Yet I think the suggestions are well worth 
considering imder any conditions. 

DISCUSSION. 

Dr. Bebnard Bartow, of Buffalo, said that he had been interested in 
the presentation of Dr. Packard's views from the point of view of the 
climatic influence on tuberculous disease. His own experience was that, 
with the best climatic conditions for constitutional improvement, move- 
ment of the joint was of no advantage, and that fixation, with protection 
as perfect as possible, was essential until arrest of the disease was assured. 
An recognized the value of climate and hygienic conditions in modif3ring 
the local disturbance, but any relaxation of local treatment seemed a 



158 TREATBIENT OF HIP-JOINT DISEASE. 

faulty plan. He had also been interested in what had been said by Dr. 
Taylor as to the combined treatment, and conrndered the method advo- 
cated by him was ideal for almost any period of the disease. The caaea 
reported showed its advantage, especially in the early stage. The disease 
was one which could not be trifled with, and the more quickly the tuber- 
culous focus is removed, the better the chance of arresting the process 
and diminishing the effects of the disease. 

Sir William Hinqston, of Montreal, was invited to take part in this 
discussion. He said he had been here long enough to learn, and with 
pleasure, that earlier surgical interference was resorted to than formerly. 
The question presenting itself as to when and how to interfere was one 
of great difficulty. He had long ago come to the conclusion that to keep 
a child for an indefinite period with an extending apparatus was a mis- 
take. When should one give up all hope of surgical interference other 
than operative was a difficult question. The judgment of the surgeon 
must come in to determine how long to wait. If we erred at all, it should 
be rather upon the side of earlier operative interference; for, when pus is 
present in considerable quantities, and the tissues are beginning to dis- 
integrate, it is useless to wait. He thought the late Dr. Sayre had placed 
the profession under the deepest obligation by advocating earlier surgical 
interference than was usually practised previous to his time. In a great 
number of traumatic cases — and most of them he thought were trau- 
matic — one could obtain a desirable result by other means without re- 
sorting to the knife; but, in those cases where operative interference 
seemed to be indicated, that interference should not be needlessly delayed. 
He would like to ask. What are the advantages of the anterior incision over 
the one advocated and practised generally? His own practice had been 
to make use of the horseshoe incision, as it seemed to lend itself better to 
drainage. By practising the most careful aseptic surgery, however, there 
should be no additional risk from the anterior incision; but he would be 
glad to leam what are the ages presented by the anterior incision. 

Dr. G. G. Davis, of Philadelphia, said that in cases of acute tuberculous 
inflammation he had not infrequently trephined the head of the bone, mak- 
ing six or eight small perforations. By this means one was able to cut 
short the acute symptoms, the disease apparently subsiding. In several 
instances in which he had done this and discharged the patient, the symp- 
toms had reappeared: in other words, while operative procedures would 
modify the symptoms, they would not cure the disease. If Dr. Taylor 
would deliberately excise all of the disease, that was a different matteri 
but operative procedures did not in themselves cure the affection, and 
did not relieve one of the necessity of practically relying upon rest as a 
curative measure. 



DISCUSSION. 150 

Dr. v. P. GiBNBT, of New York, said that Dr. Thomdike's paper mm 
an exoeDent and valuable one, but, being purely statistical, hardly ad- 
mitted of discussion at this time. With regard to Dr. Taylor's paper 
he would say that he believed that by the aid of the X-ray, or even with- 
out it, one could recognise a suspicious mass under the trochanter, or the 
femoral vessek, or in the gluteal region, and could feel sure that there were 
present the {Hroducts of disintegration. He believed it to be a good plan 
to incise these cases, cutting down upon the points of infiltration, squees- 
ing out the contents, and treating the case exactiy as one would an abscess 
which was aspirated. He would advise against the use of chemicals, and 
recommend sewing up the wound without drainage, and then applying 
a skin-fitting plaster of Paris bandage and an ice-bag, and keeping the 
diild at rest for some days. He had found a number of cases in which 
the night cries had been terrific, and nothing had been accomplished by 
traction or fixation, in which relief had followed almost magically the 
treatment just outlined. His objection to using chemical disinfectants 
or doing a more exteuAve operation was that one was apt to get beyond 
the area of the diseased tissue which one was trying to eliminate. Having 
carried out the treatment described, an X-ray photograph should be 
taken to determine whether or not any disease remained. If the indi- 
cations of disease returned, the operation should be repeated, thus doing 
away as rapidly as possible with the products of the disease. The X-ray 
should be the guide as to the amount of traction and the length of time 
it should be kept up. 

Dr. NswTON M. Shaffer said that Dr. Taylor had brought out a very 
interesting question, raised by Lorenz especially, concerning the removal 
of the apparatus in a stage which, the speaker said, he personally felt was 
too early. It seemed to him there was one simple test which would tell 
readily when the patient was in a condition to have the apparatus removed. 
The initial limp was the danger signal, and all the way through the in- 
ability of the patient to bear the weight of the body upon the joint was 
clearly marked. When one reached the point where the patient had re- 
covered from the disease, if the patient then showed a disposition to bear 
his weight upon the limb, one must discriminate between the disability 
due to disease and the disability induced by the prolonged use of appara- 
tus. Weight-bearing was the test of whether or not it was safe to leave 
off the apparatus. He had seen many cases in which the patient had 
recovered without knowing it, and had come back after several years of 
indifferent treatment, and, on the removal of the apparatus, had walked 
with a gait simply due to the prolonged use of apparatus. This test in 
itself constituted an almost certain indication of the time when the appara- 
tus could be safely removed. He was convinced that the disability of the 
disease was a distinct and important factor, and that the disability due 



160 TREATMENT OF HIP-JOINT DISEASE. 

to the use of the apparatus could be readily recovered from, so that he 
did not fear the atrophy and disability produced by the prolonged use 
of apparatus. He would rather a patient would use an instrument a year 
too long than take it ofif a few months too soon. He was of the opinion 
that ordinarily the apparatus was not kept on long enough. 

Dr. Clarence L. Starr, of Toronto, said he would like to know more 
about the case dying on the table of carbolic add poisoning. Two or 
three years ago he had presented to the Association the idea of early 
curetting for tuberculous disease, and the swabbing out of the sinuses 
with pure carbolic add. At that time it was suggested that it was ad- 
visable to wipe out the cavity with alcohol. This seemed to him a great 
mistake, and he believed the case of carbolic add poisoning was due to 
this one feature. He had swabbed out such cavities many times for 
several years. The use of carbolic acid formed a wall against absorption, 
but by the use of the alcohol thb protecting wall was dissolved away and 
absorption of carbolic acid favored. He was glad to see that there was 
a tendency to treat the broken down tissues by incision and curettage, 
and also the closing up of the wound afterward. This was just what he 
had advocated in his paper. He was of the opinion that it was dangerous 
to say that a so-called tuberculous abscess should be opened and drained. 
Possibly the statistics presented by Dr. Thomdike emphasised thiS; be- 
cause they showed such a large number of sinuses in the out-patient ser- 
vice. He had met with no such number of discharging sinuses in an out- 
patient service in the Children's Hospital in Toronto. Where an abscess 
appeared to be progressing, the case was sent into the hospital, was thor- 
oughly curetted and dosed up, and after a certain length of time the 
patient was returned to the outdoor department. Reference was made 
to a case in which he felt certain that the head of the bone had separated. 
On cutting down upon it, he f oimd not only this sequestrum, but the neck 
of the bone of a worm-eaten appearance and apparently entirely beyond 
the possibility of recovery. Not having the consent of the parents for 
a more extensive operation, he curetted the parts and swabbed with pure 
carbolic acid. The wound was closed temporarily. Much to his surprise, 
the whole of the disease subdded, and the child made an uninterrupted 
recovery; and there was now a very large amount of motion, much greater 
than he had anticipated. 

Dr. GoLDTHWAiT Said he hoped that in publishing the discussion the 
word ''combined" would not be lost sight of, because this seemed to him 
to be a very large part of the treatment. The disfavor in which exsection 
had been hdd in the past was probably because the general surgeons con- 
sidered the patients cured as soon as primary union had taken place, when 
some of the tubercular disease must still be present. Dr. Taylor had com- 



J>fSCUS810N. 1<» 

blued operative treatment with conBervative mechanical treatment, thus 
protectiiig the vuhierable joint for a sufficient length of time for complete 
dcatriiation to take place. 

Dr. E. H. Bbadford, of Boston, said he desired to emphasise what had 
just been said by Dr. Goldthwait. He was sure Dr. Taylor did not advise 
going back to the old way of curetting, putting up in plaster of Paris, 
and after a few months pronouncing them cured. The after-treatment 
was very important. He understood Dr. Taylor to say that, when there 
was more detritus than nature could take care of, one should cut down and 
remove this. The objection to this method was that one could not 
treat the hip joint like the knee or ankle, as the acetabulum cannot be 
thoroughly curetted in many instances. 

Dr. B. E. McKenzie, of Toronto, thought the constitutional treatment 
referred to by Dr. Packard should receive more attention. It had been 
his experience in Toronto, where the condition of the poor was better than 
in some larger cities, that, when the patients were kept in the orthopedic 
hospital for a short time, their condition improved, and on sending them 
home their condition became worse again, necessitating readmission to 
the hospital. At this season of the year these patients were kept in tents 
at the hospital, the sides of the tents being rolled up, if desired. These 
patients lived outdoors both summer and winter, the tents being heated 
in the cold season to about 50^ F. Those who had not tried this plan of 
treatment would be surprised to note the good effect of this mode of 
treatment. Dr. Taylor had made a plea for giving up the prolonged 
treatment, and avoiding the atrophy resulting therefrom. The speaker 
thought Dr. Taylor was right in a large measure, but feared he would 
overstep the bounds. Sometimes much atrophy was apparently due to 
trauma. For example, a woman of thirty-eight, who had been well up 
to two months, when she fell and struck the left trochanter on the side- 
walk, developed a marked atrophy. When he saw her, two weeks later, 
there was an atrophy of H inches. 

Dr. RiDLON desired to put on record a case showing the other side of the 
question. He said that yesterday he had seen with Dr. Taylor a large 
number of these cases, and he had no doubt of the excellent work done 
by Dr. Taylor according to this method. Some years ago Dr. Mudd, of 
St. Louis, did this operation of erasion on a boy, K. S., and he was treated 
by Dr. Hodgen for over a year by traction with a hip splint. The case 
then came under the care of Dr. A. J. GiUette, who treated him for about 
one year. The boy then came under the speaker's care, and was treated 
by the long-traction hip splint. The wound had remained closed ever 
since the operation. After two years of treatment with the splint the 



162 TREATMENT OF HIP-JOINT DISEASE. 

case was seen by Dr. Mudd, who advised removal of the splint; but it 
was not removed until a year later. Within a fortnight there was a flexion 
deformity of 45^ and absolutely no motion, and such great tenderness 
that the boy could not walk. Traction in bed for three weeks corrected 
the deformity, and the range of motion again returned. He had treated 
the case for another year and a half, and again took off the sphnt. There 
was a range of motion of a little less than half in all directions. Slowly 
the hip stiffened up, and the leg finally had a shortening of 2 inches. Sen- 
sitiveness gradually passed away, and the boy walked for a year with a 
crutch. At the end of three years' walking without any protection, the 
boy died of tubercular meningitis. It was, therefore, not possible to cure 
all of these cases or to get the good results that had been obtained by Dr. 
Taylor. 

Dr. G. G. Davis said he would like Dr. Taylor to define very clearly the 
cases in which he would advocate the operation, and the time for it. In 
endeavoring to follow up a sinus to its focus, he had not personally secured 
much success. He agreed with Dr. Bradford that the X-ray was not 
always reliable, because it did not show just what the disease was. In 
one case, which he recalled, the X-ray photograph showed marked disease 
of the head and neck; but on cutting into the joint he had found abso- 
lutely no pus in the joint, and the head and neck apparently healing. 
The only indications of really active disease were extra-articular. 

Dr. Wbigsl asked the method of procedure ^en the disease was 
limited entirely to the acetabulum. In this connection he would present 
the picture of such a case, to show also that bone atrophy does occur in 
the early stages long before it could be attributed to non-use, — a very 
important point to be borne in mind. Sometimes the amount of atrophy 
of bone and the arrest of its growth were due to the extent of the disease, 
and were not greatly modified by the length of time protection was used. 

Dr. Packard, in closing, said that he had intended to say that, usually, 
he mobilized the joint for a year or more, but he wished to emphasise the 
fact that earlier functional use was often possible. 

Dr. Taylor said that Dr. Bartow had evidently misunderstood him 
with regard to the mechanical after-treatment which he always used in 
conjunction with the operation. With regard to the questions of Sir 
William Hingston, he would say that the anterior incision was employed 
in order to do as little damage as possible to the muscular structures. 
The incision passed through the intermuscular septum and down to the 
capsule. Drainage was not employed except a small wick passing down 
to the lowest point of the bone cavity, to allow the escape of serum and 



DISCUSSION. 168 

blood. Hik was removed on the third or fourth day. Thorough erasion 
was indicated, if it were done at all, and hence not only ahould the debris 
be removed, but the waUs thoroughly curetted, and then disinfected be- 
fore closing the wound by suture. Firolonged mechanical protection was, 
of course, essential. He made use of a spica of gauze, and then made 
traction high up on the thigh. With regard to cutting beyond the area 
of the disease he would say that he worked with the X-ray photograph 
at his side, using this as his guide. He certainly did go a little beyond 
the diseased area; but he trusted to the disinfectants, together with the 
subsequent circulatory changes, to complete the destruction of the bacilli 
in the walls. If a person fractured the leg, and it was put in plaster for 
six weeks, on the removal of the plaster the part would not be foimd in 
a condition for weight-bearing. Hence he did not agree with Dr. Shaffer 
that power of weight-bearing should be our guide in removing the brace. 
We should be guided by the joint symptoms. Reference had been made 
to wiping out the cavity with carbolic acid. His own method had been 
to fiU the cavity with carbolic acid or formalin solution, and not merely 
swab it out. Moreover, a sharp curette was employed. The keynote of 
the paper was certainly the combined treatment, as stated by Dr. Gold- 
thwait. The tubercular cavity should be cleaned as thoroughly as possi- 
ble. With r^ard to post-mortem X-ray examinations, in reply to Dr. 
Bradford's question, he said he had had no experience, and did not know 
that the same result would be obtained with the X-ray tmder such con- 
ditions. The clouding, he had always thought, was due to a circulatory 
condition. In the case referred to by Dr. Ridlon he would judge that 
the after-treatment had not been sufficientiy protective or watchful enough 
or the original erasion sufBcientiy radical. In the acetabular cases referred 
to by Dr. Weigel one could go outside of the neck and reach the r^ion. 
Sometimes the upper part of the head would have to be chiselled away in 
order to gain access to the disease. Primary acetabular disease is, how- 
ever, rare, and the exception. 



VI. 
A NOTE ON THE FOOT OF THE AMERICAN NEGRO. 

ALBERT H. FREIBERG, M.D., AND J. HENRY SCHROEDER, M.D., 
CINCINNATI, OHIO. 

It would appear that the wide-spread notion of the flatness 
of the negro's foot had its origin in this country. The bones 
of the negro's normal foot differ in no regard from the white 
man's, as far as their individual shapes are concerned, excepting 
that of the os calcis, the length of whose posterior process is ad- 
mittedly greater in the negro. Nevertheless, the flatness of the 
negro's foot has become proverbial, and has given rise to the 
saying that " the hollow of his foot makes a hole in the groimd." 
As a racial characteristic of the aboriginal negro, the flatness 
of the plantar arches has been disproved by Herz and Muskat 
in recent publications. The former has shown concluavely, in 
a large number of observations made in Africa, that a well-de- 
veloped and easily apparent plantar arch exists far more con- 
stantly in the negro, as there found, than in an equal number 
of Europeans. While this is doubtless true, there can, on the 
other hand, be little uncertainty that the homely observation 
of the contrary condition in the American negro has some basis 
in fact. Abundant opportunity for superficial examination of 
adult negro feet in this country brings with it the impression 
that flat foot is present in the negro with unusual frequency as 
compared with the white. The present investigation is offered 
as incomplete, in so far as the number of observations is too 
small for binding conclusions, but as being rather comdncing 
in its results, nevertheless. 

There were used as material for the observations herewith 
presented 88 feet of adult negroes, who were walking patients 
in the wards of the Cincinnati Hospital. A large proportion 
of them were under treatment for venereal disease. Eight of 
these 44 were women. The men were practically all engaged 

Presented at the Seventeenth Annual Meeting of the AsBOciation, Waehlngton, 
D.G., Ifay 11-14, 1903. 



A. H. FREIBERG AND J., H. 8CHR0EDER. Ilt5 

in heavy laboring occupations. Impressions of the feet were 
taken by the iron and tannic acid method. Attention was paid 
particularly to the flatness as shown by the impression and to 
the condition of the great toe. Of this series but 16.2 per cent, 
of the feet lacked both hallux valgus and marked flattening of 
the arch. Hallux valgus without descent of the arch was pres- 
ent in 27 per cent., while marked flat foot was observed in 56.8 
per cent. Of the cases of flat foot, 92 per cent, had accompany- 
ing hallux valgus. 

For the sake of comparison a series of impressions of the feet 
of white patients was taken. Their occupations were noted, 
and were found to be about the same as those of the negroes. 
Thirty-four feet were examined in twelve men and five women. 
Of this number 59.2 per cent, had neither hallux valgus nor flat 
foot. Hallux valgus without flat foot was present in 35 per 
cent., while but 5.8 per cent, had flat foot, being two cases in 
both of which hallux valgus was present. It was furthermore 
noted that 41 per cent, of the white feet presented hallux valgus, 
with or without flatness, while in the negroes this percentage 
was 79.5. This frequency of hallux valgus seems of especial 
importance, since it may be considered purely as the result of 
deforming foot-gear. 

Although, as before remarked, the number of observations 
is too small for definite conclusions, the variation in the figures 
is quite striking. Not only is flat foot much more frequent in 
the n^ro, comparatively speaking, but distortion of the great 
toe is relatively twice as frequent as in the white. 

In the belief that an interesting comparison would result, 
impressions were taken of the feet of twenty colored children 
between the ages of thirteen and three years. Of the forty feet 
examined, 75 per cent, had normal feet, 25 per cent, had flat 
foot, of which 80 per cent, were associated with hallux valgus. 
Hallux valgus was present in 25 per cent, of the whole number. 

By far the greater niunber of negroes in Cincinnati have more 
or less admixture of white blood in them. On this account note 
was made of the color of all the adult negroes examined. There 
were noted as dark, 34; as of mediiun or light color, 54. Of those 



166 FOOT OF THE AMERICAN NEGRO. 

noted as dark, 53 per cent, had flat foot, and 70.5 per cent, had 
toe valgus. Of those classed as medium and light, 59 per cent, 
had flat foot, while 87 per cent, had toe valgus. It would thus 
appear that these deformities were somewhat more frequent in 
the lighter-colored than in the dark, although the difference 
cannot be considered great. In fact, it appears that, consider- 
ing the small number involved, this difference can* be ignored. 
Were the nmnber of observations sufficiently large, it would 
seem justifiable to draw the following inferences: — 

1. Flattening of the arch of the foot is much more frequent 
in the American negro than in his white neighbor. 

2. Hallux valgus is likewise more frequent in the negro than 
in the white American. 

3. The well-arched foot occurs in the American negro with 
sufficient frequency to establish it as the normal. 

4. While flattening of the arch is more conmion in the negro 
child than in the white, the normal foot preponderates decidedly. 

5. From this it would be fair to conclude that the flat foot 
of the adult American negro has developed after the period of 
childhood in the greater niunber of cases. 

6. The deforming effects of footwear are much more evident 
in the adult negro than in the white man of the same class. This 
is shown by the fact that decided valgus of the great toe is much 
more frequent. 

There require to be explained the cause of the frequency of 
flat foot in the negro child and its increase in adult life. The 
great frequency of rickets in negro children is well recc^nized, 
and its manifestation in bow-legs and knock-knee is qmte fa- 
miliar. This alone would account for a considerable portion 
of the flat foot in children. However, it will be noted that even 
in these hallux valgus was present in 80 per cent, of the flat- 
footed. This, together with the marked frequency of hallux 
valgus in the adult, would make it seem likely that the effect 
of dioes in distorting the feet is especially marked in the negro, 
both child and adult. 

This might be explained by the fact that the negro foot is 
wide in its anterior portion, and therefore especially prone to 



A. H. FREIBERG AND J. H. SCHROEDER. 



167 



compression. The length of the heel would, however, seem also 
to merit consideration. It would have the effect of shortening 
the shoe for the fore part of the foot, since it virtually displaces 
the ankle forwards. It would seem that a negro's foot cannot 
be covered with a white man's shoe with impunity. 

Should future investigation agree with the above findings, 
it would become necessary to abandon the idea that a flat plantar 
arch is an hereditary and racial characteristic of the American 
negro; but this condition would have to be regarded, in part at 
least, as the injurious result of shoes of improper construction. 

The excuse for presenting so incomplete an inquiry is to stim- 
ulate further research into a question of importance, not only 
in its piu^ly ethnologic aspects, but also as it pertains to the 
theory of development of one of the most frequent deformities 
of all civilized people. 





Ai>in.T 
Nbobo. 


Adult 
Writx. 


Nbom 

CmtDRSH. 


Number examined (feet) 

Percentage of flat feet 

Hallox valgns without flat foot . . . 
Without flat foot or hallux valgus . . 

Hallux valgus present in 

Of flat feet, hallux valgus present in . 


88 

66.8 

67% 

16.2% 

79.6% 

92.0% 


34 

6.8 

36% 

69.2% 

41% 

100% 


40 
26 
6% 

76% 
26% 
80% 



vn. 

A STUDY OF A CASE OF LATERAL CURVATURE OF 
THE SPINE: A REPORT ON AN OPERATION FOR 
THE DEFORMITY. 

Fbom the Orthopedic Department of the Presbyterian 
Hospital, Atlanta, Ga. 

michael hoke, m.d. 

Lateral curvature of the spine without bone deformity is 
a simple problem. Lateral curvature with osseous deformity 
in children, whose bones are very flexible, though a more diffi- 
cult problem, permits correction to a greater or less extent by 
properly fitting plaster jackets. Osseous deformity in children, 
adolescents, and adults, whose bones are stiffer and less jrield- 
ing, has permitted very Uttle, if any, correction. The method 
of treatment has been about the same as for the younger flex- 
ible cases, — plaster jackets, removable jackets, exercises, and 
various combinations of these. The figure of most of the sever- 
est cases is as bad when wearing apparatus as when unsupported. 

Like all orthopedic surgeons, the writer has been harassed 
by the uncertainty of prognosis, — the knowledge that, save in 
the very young cases, the osseotis deformity vxndd not be affected 
at aU by exercises and jackets. 

Fourteen months ago the study of this case was begun, — 
an effort to find some operative means by which the deformity 
of the ribs could be changed, the hump decreased, the depression 
in the back filled in. 

The facts recorded here did not come in the sequence with 
which they are connected in this paper. Many experiments 
were made which proved to be valueless. Many designs of 
instruments and apparatus other than those shown in the illus- 
trations were made, with no result save to indicate how better 
ones should be made. 

Presented by invitation at the meeting of the American Orthopedic Association, 
Washington, D.C, May 11-14, 1903. 



MICHAEL HOKE. 



16ft 



In this case a change in the bones has been made. A result;, 
though far from perfect, has been obtained, which was not pos- 
sible without the operative procedure herein reported. The 
writer is not yet through with the case; but he feels that, with 
due regard for that conservatism which should always control 




Fig. 1. 



one's judgment, he may report the work done in connection 
with this case. 

Patient. — Age, sixteen years aiid six months. 

Complaint. — Curvature of the spine. 

Pa^i History. — Measles at ten; mumps at thirteen; whooping-cough at six; 
malaria everj'' spring from nine to thirteen; scarlet fever at eight, — a very 
mild attack; "gastritis" at thirteen, — attack lasted two months; has always 
been delicate. 



170 



LATERAL CURVATURE OF THE SPINE. 



Present History. — May 1, 1902. Histoiy of deformity: When she was 
eight years old, the dressmaker first noticed that one hip and one side were 
larger than the -other. Nothing was done to correct the condition until 
she was nine years old, when a physician was consulted, under whose care 
she remained until she was twelve. During these three years she was frail. 




Fio. 2. 



Exercises were prescribed, which were taken mainly with dumb-bells, pullex's, 
and other machines. The posture habit received no attention. Her gen- 
eral condition received no medicinal treatment. Under this treatment she 
thinks the condition remained the same. During this period the deformity 
was not very noticeable when the clothes were taken olT. Observed with 
the clothes on, the condition was not noticeable. She then went home, 
and continued the exercises one year. During this period she got worse. 
She was then taken to an "Institute." A brace was applied, exactly like 



MICHAEL HOKE. 171 

the one shown in Fig. 1. She went home, and came back again at the end 
of six months to have the pads on the brace changed. During these months 
she got very much worse. She then returned to the "Institute" to be treated. 
She remained there one year. The back was steamed, electricity, "two 
kinds," was given every day, exercises were taken chiefly with machines. 
She got worse during this time. 
Examinatian: — 

(a) General Condition, 

Patient is pale, nervoas, tongue coated, constipated, tired all the time, 
has headaches frequently, sleeps badly. 

Heart sounds normal, areas of dulness normal, apex within nipple line, 
pulse 92 to minute, lungs normal, hemoglobin 65 per cent., no count of 
corpuscles. Abdomen negative. Urine negative. - 

(b) Posture and Curiae and Conformation of Body. 

See Fig. 2, kodak picture taken May 16, 1902. 

The patient stands with her head inclined toward the right. The right 
shoulder with pendent arm goes forward: the inferior angle>of the right scapula 
is very prominent, projecting backward about two inches further than the 
left. The left shoulder with the arm is backward towards the spine: the 
inferior angle of the scapula is not so prominent as it should be, and lies close 
to the spine. The left hip is very prominent and forward: it is higher than 
the right, which is back of its normal position. The weight of the body is 
thrown on the right leg. When she stands with feet together, the left leg 
appears shorter than the right. The left heel does not touch the ground. 
Measurements of the two legs show no real shortening. The apparent short- 
ening is due to tilting of the pelvis and adduction. The outline of the left 
side shows a deep concavity; that of the right side is slightly convexed; the 
left nipple is a little lower than the right. Over the splenic area the anterior 
part of the left ribs forms a decided prominence. The left ribs from the 
fourth to the twelfth are displaced (rotated) forward, so that the area of the 
thoracic wall in the back formed by these ribs is deeply sunken. This is 
produced by the fact that the left ribs are rotated forward, and their back- 
ward-arching from the angle out has been flattened. This is shown in Fig. 3, 
in which the patient was photographed as she was bending forward. The 
deepest portion of the sunken area lies (presuming the patient to be stand- 
ing) in front of and below the inferior angle of the scapula. (See crease in 
skin in Fig. 1, photograph with brace on.) The fifth and sixth ribs are dis- 
placed (rotated) further forward and flattened more than the others involved 
on the left side of the spine. 

Tlie ribs on the right side from the fourth to the twelfth form a promi- 
nence. This decided deformity of the right ribs is seen in Fig. 3. The prom- 
inence is produced by rotation backwards of the ribs and by the fact that 
the normal-postero-convex curve of the ribs near the angle has been greatly 
increased. 

The curve of the spine is an S-shaped one, extending throughout the length 
of the spine. 



172 



LATERAL CURVATURE OF THE SPINE. 



Beginning at the base of the skull, with the head inclined to the right, 
the spine curves to the left to the first dorsal, then slightly to the right to the 
fourth dorsal, then very acutelj' to the right, as if, with the articulation of 
the fourth and fifth dorsal vertebra* as the plane of motion, the section of 
the body from the fourth dorsal vertebrae (inclusive) up had been shifted to 
the left upon the lower segment (from fifth dorsal vertebra, inclusive, down). 




Fig. 3. 



Thus the fifth spine is about one inch below and to the right of the fourth 
spine. Then this curve to the right continues to the eighth vertebra, at 
which point it turns to the left, crossing a plumb at the twelfth, and con- 
tinues into the lumbar region. 

The patient sits with the head, slioulders, arm, and hips in the same posi- 
tion relative to one another as they are when standing. The normal lumbar 
curve has been greatly increased, so that the patient, when standing, is very 
"sway-back." The costal margin in front is for that reason very promi- 
nent. 



MICHAEL HOKE. 



173 



If a perpendicular plane is let fall through the transverse diameters of hips, 
shoulders, and chest of a normal individual, these planes will be approxi- 
mately parallel. Here they are inclined to one another. 

Fig. 4. — Let line HH represent the projection of a plane passed perpen- 



l,T 



^~ /ir 



J 






^C4 tt 



?? 



dicularly through the transverse diameter of the hips in the position they ought 
to occupy. Pass similar planes through the transverse diameters of the hips, 
thorax, and shoulders in their present positions, and project them upon the 
ground. Let line HH be the basis from which the rotations of the hips, 
thorax, and shoulders of the patient, can be approximately estimated. Then 
LH, etc., represent the positions of left hip, left side of thorax, and left shoulder 
in the postures the patient assumes in sitting and standing, and the arrows 
Ik, etc., the directions in which the left hip, etc., have rotated. RS, etc., 




Eio. 5. 



174 LATERAL CURVATURE OF THE SPINE. 

ijIgTesent the right shoulders, etc. The torsion in the body can be appreci- 
ate from this diagram, which is only an eye estimate of the rotation df ithe 
parts hiQKitioned. 

There is no rotation forward, and consequent flattening of the left first, 
second, third, and fourth ribs, and no bending backward of the first, second, 
and tliird ribs on the right side. The cun^e backward in the fourth rib on 
the right is a little increased, but not enough to be striking. The section of 
the chest above the fifth rib may be regarded as structurally sjrmmetrical, 
though it shows a postural curve. Below this segment the aB3'mmetry of 
the skeleton has been produced. 

The greatest change in the spine is at the fifth, sixth, seventh, and eighth 
vertebrae. These vertebrae are rotated more to the right than the others. 
The deepest part of the sunken area in the left side arises from the fact that 
the fifth, sixth, seventh, and eighth ribs are displaced farther forward and 
flattened more than the other ribs on the left side. The greatest amount of 
bending backward of the ribs on the right side has occurred in the fifth, sixth, 
seventh, and eighth ribs: The section of the thorax formed by these vertebrae 
and ribs has become most markedly deformed. 

The segment of the chest from the fourth to the eighth vertebrsp seems 
to take no part in the motions of the spine: this section seems fixed. The 
spine is unnaturally flexible at about the tenth dorsal to the second lumbar 
vertebra. Lateral flexion of the body is accomplished mainly by the motion 
between the tenth, eleventh, and twelfth dorsal and first lumbar vertebrae. 
The trunk can be laterally flexed to the right about half as far as the left. 

The experiments below were made upon a cadaver taken without selection 
from a number in the head-house. The body was that of a man, who had 
been a laborer. The ribs were thick, hard, and resistant, the ligaments strong. 

The muscles of the back were cut away. The fttemum wUh the ribs attached 
was left intact. The thoracic viscera were not removed. The pelvis was 
made steady in a box. 

Tlie bony part of the thoracic cage is made of vertebne, cartilages, ribs, 
and sternum. Let a "thoracic element" be a vertebra, and its attached 
ribs not united or united in front by the sternum, or indirectly by attach- 
ment to the costal border. The shape of such an element is shou-n in Fig. 5. 
Fig. 5 is a photograph of the fifth element taken from the subject after the 
experiments below were made. Mark the centre of the vertebra, mark the 
opposite point on the sternal portion of the element. Find points on the 
ribs equally distant from the sternal point. These points are equally dis- 
tant from the centre of the vertebra. 

Fig. 5. If bd and be are equal, then ad and ae will be equal. Tlie symmetry 
of tJ\3 figiire is striking. Support the element upon a rod in the position of 
its antero-posterior diameter. The element balances long enough to be pho- 
tographed. (See Fig. 6.) These two experiments were made with the first, 
jgecoad, third, fourth, and fifth elements. The results were analogous in each 
- instance. The first seven elements are to be called "closed elements" (com- 
plete bony rings) for the reason that the ribs of each are united to thejr fel- 
lows by the sternum. These elements are rigid, and they are rigidly held 
together in the front by the sternum. The firmness of the thoracic cage 



MICHAEL HOKE. 



175 




Fio. 6. 




Fig. 7. 



176 LATERAL CURVATURE OF THE SPINE. 

behind, along the spine, must depend upon the rigidity of each element, 
and the fimmess with which the neighboring vertebne and ribs, out as far 
as the angles, are held together by the various ligaments. 

The eiglith, ninth, and tenth elements are indirectly "closed," since they 
are joined to the continuous costal border; but these elements are of neces- 
sity not as rigid as the first seven. The eleventh and twelfth are not "closed." 

Fig. 7 shows the subject with straight spine and symmetrical thorax suffi- 
ciently suspended to keep it from bending forward. 

Fig. 8. The thumb of the left hand is pressing fom^ard upon the end of 
the left twelfth rib. The end of the left twelfth rib could be pressed forward 
easily some little distance. The index finger of the right hand points to the 
right twelfth rib, which rotated backward. Pressure forward was made 
upon the left eleventh and upon the tenth ribs at the angle in the same man- 
ner. There was much less disciu^ion forward of the left tenth rib than the 
left eleventh and twelfth, less rotation backward of the right tenth rib than 
of the right eleventh and twelfth ribs when subjected to analogous press- 
ure conditions. Pressiu-e forward upon the left ninth, eighth, seventh, and 
sixth ribs, gave progressively less discursion forward of the ribs pressed upon 
than was seen when the foregoing ribs were similarly pressed forward, and 
progressively less rotation backward of the corresponding right ribs. In 
the eighth, seventh, and sixth ribs the movement produced was very slight. 
Extremely little rotation of the vertebrae was produced. 

Fig. 9. The eighth rib was completely severed at the point marked by the 
thumb in the illustration. Forward pressiu^ was made by the thumb upon 
the end nearest to and still attached to the spine. This end could be pressed 
forward three-quarters of an inch or more easily. There was a little deflec- 
tion of the eighth vertebral spine to the left, indicating rotation of the ver- 
tebral body to the right, perceptible to the eye, but not enough to show in 
the photograph. There was also much more rotation backward of the eighth 
and nintli ribs than was seen when pressure was made at the same site before 
the rib was cut. ' ' *' 

The index finger is making pressure at the same site as the thumb in 
Fig. 10. Tlie second finger points to a discursion forward of the rib below 
(pulled forward by tlie anterior corto-transverse ligament between it and 
the vertebra above). This was perceptible to the eye. The movement was, 
however, not sufficient to show in the photograph. 

Fig. 11. The left seventh, eighth, nintli, and tenth ribs were cut where 
the rib tiu'ns forwanl. Pressure was made by the fist upon the ends nearest 
the spine. These ends could be easily pressed forward an inch. There was 
enough rotation of the \ertebrai to the right to be shown in the photograph 
(see deflection of spine of the vertebme to the left). There was quite a good 
deal of bulging backwards of the corresponding ribs on the right side. The 
rotation of the ribs backward on the right was much greater relatively than 
the discursion forward of the fragments pressed upon by the fist. The cor- 
responding clinical observation (the relatively greater hump on one side 
than depression on the other) can be made by the examination of any osse- 
ously deformed case. It was far easier to bend the spine laterally than it 
was before the ribs were cut. 



MICHAEL HOKE. 



177 




Fig. 8 




Fio. 9. 



178 



LATERAL CURVATURE OF THE SPINE. 




Fio. 10. 




Fig. 11. 



MICHAEL HOKE. 



179 



Fig. 12. A knife was passed between the transverse processes on each 
fflde of the vertebral column towards the spine, cutting the anterior corto- 
transverae ligaments. The weight of the thorax easily curved the spine 
laterally, and rotation of the elements was vastly easier. The eleventh and 
twelfth elements are not closed figures. 




Fig. 12. 



Deductions. 



Pressure forward at a through the mediation of the middle costo-trans verse 
ligament and vertebra rotates the vertebra to the right and the opposite 
rib backward. A slight rotation of the vertebra is sufficient to produce a 
greater arc of motion at b, since h is the end of the long arm of the lever. 
A closed element, since it is a bony ring, cannot give in to pressure at a point 
without yielding somewhere else in the ring. The ribs in the closed elements 



Fig. 13. 



are to be regarded as props to the spine. Tliey are forces, since they trans- 
mit the weight of the thorax, its contents, the head and upper extremities, 
to the spine. In the noimal, symmetrical, closed element the force of corre- 
sponding right and left ribs is applied to the spine in the same plane. (See 
Fig. 14, arrows a and b.) They must balance one another. 

When forward pressure was made near the left angle of the rib of a com- 
plete closed element, the ribs of which were thick and resistant, there was 



180 LATERAL CURVATURE OF THE SPINE. 

extremely little yielding at the point of pressure, and extremely little rota- 
tion of the attached vertebra, and extremely little rotation backward of the 
opposite rib, because the element was rigid, it would not yield to pressure. 
When, however, the left rib of a closed element was cut and forward pressure 
was made on the fragment nearest the spine, that fragment could be easily 
pushed forward three-quarters of an inch or more, the attached vertebra 
<*ould be rotated to the right, and the corresponding right rib rotated back- 





FlG. 15. 

wards. In other words, pressure at a. Fig. 15, produced rotation of the 
vertebra in direction of arrow b and greater rotation backward of right rib 
in direction of c. Here, again, the greater discussion at c appears, as the re- 
sult of this |K)int being at the end of the long arm of the lever. Thus, if the 
ribs are firm, pressure forward on the angle of a rib can but little affect the 
figure of the element by producing yielding at the point of pressure and rota- 
tion of the vertebra. But, when the equilibriimi of the forces on either side 
of the vertebra (from integrity of the ribs) is destroyed by cutting a rib, 
then it is possible to rotate the vertebra to produce backward motion of the 
angle of the rib opposite to the one cut. Pressure at c produced rotation the 
reverse of that produced b}' pressure at a. The same result was obtained, 
as mentioned above, but to a greater degree, progressively, as more ribs were 
cut, the ligaments being still undisturbed. Thus, so long as each element 
is symmetrical and unyielding, the ribs possess their incremental power of 
preventing lateral curvature, rotation of the spine, and deformity of the 



> '.LjU' 



t 



Fig. 16. 



thoracic cage. But, if an element yields, the ribs being flexible or having 
been made so artificially, then by pressure at the right place one may influ- 
ence the element by corrective force. Each rib in a symmetrical element 
must equally oppose the force of its fellow on the opposite side, the two ribs 
equally bracing the vertebra. 

When the anterior costo-transverse ligaments connecting a number of 
elements were severed with the knife, it was very easy to bend the spine 
laterally, and to rotate the whole thoracic cage to an extent limited, but 
greater than normal. 



MICHAEL HOKE. 181 

Let abc be a rod resting at it^ centre b upon a pivot ; d and e are equal weights 
Buspended from the ends; xy^ a pedestal; op and o'j)', slightly elastic bands 
of equal size. Depress c, remove the pressure: as a result, the rod will oscil- 
late and finally come to rest. Add to the weight e, then c will descend in 
some proportion to the weight added, and the yieJding of elMstic band op. 
Remove additional weight, the rod will oscillate and come to rest again. 
Turn back, and look at Fig. 7, a syumietrical element balancing on a rod. 
All symmetrical elements are balanced, and a symmetrical thorax is balanced 
upon the spine. 

Observe the analogy of Fig. 17 with Fig. 16: x equals pedestal and pivot, 
a vertebra of an element; element abc and elements above and head and 
extremities above pedestal and pivot are comparable to rod ahc and weights. 
A similar relationship exists between all elements. Then the anterior costo- 
transverse ligaments and the muscles of the back and side of trunk corre- 




FiG. 17. 

spond to the elastic bands op and o^p'. Think how a bad posture may affect 
this figiu^, adding more weight to the right or left side of the spine. The 
other ligaments of the spine were left intact in the above experiment (pro- 
ducing lateral bending so easily after the anterior costo-transverse ligaments 
were cut), and likewise the fascia between the ribs from the angle of the 
ribs to the steniiun. These must likewise play their incremental part in hold- 
ing the symmetrical elements together. It did not seem worth while — likely 
it could not be done — to try to detennuie exactly what part each one of these 
ligaments played in holdhig the frame upright. All play their part, but 
it seemed that among the ligaments the anterior costo-transverse must play 
a very prominent part m preventing lateral bending and rotation beyond 
a certain limit, regarded by the eye as normal; and how far the rotations 
occurred, except "much" or "little," seemed immaterial, too, — a detail 
that would vary with every cadaver and every living subject, dependent 
(presuming them to be symmetrical) upon the thickness and consequent 
rigidity of the subject's ribs and upon the strength, length, and elasticity 
of the anterior costo- transverse ligaments nminly, and other ligaments of 
the spine and attached ribs, and the fascia between the ribs. 



182 



LATERAL CURVATURE OF THE SPINE. 



Think how easy it is to bend the neck in any direction, and 
to rotate it: there are no ribs there. Think of the mobiUty of 
the lumbo-dorsal junction: there are no closed elements there. 
Notice the fact that between the shoulder blades there is less 




Fig. 18. 



mobility than in any other part of the spine. In this thoracic 
section are found the^ most rigidly closed elements, joined in 
front by the sternum. The component ribs are thicker, wider, 
stronger, and less yielding than their fellows in the thoracic 
wall. Observe the skeleton of a symmetrical subject. (See 
Fig. 18.) The symmetry ofj[the bony cage thorax is really mar- 
vellous. Take any point on a rib. Find analogous point on 



MICHAEL HOKE. 183 

its opposite fellow. These two points are equally distant from 
the spine; and, if not in the same horizontal plane, they are 
very near it. Corresponding intercostal spaces are of the same 
width at corresponding points, etc. 

The following facts are of great importance. The distance 
from the head to the angle of the ribs increases from the first 
to the eighth, and then decreases again. At the angles the 
ribs turn forward: thus the surface of the cage from the first 
eight angles forward forms a plane inclined forward and out- 
ward. These angles lie beneath the vertebral border of the 
shoulder blade. Naturally, on a symmetrical subject standing 
erect the shoulder blade glides forward to a normal degree 
over this inclined plane. If the shoulder on the normal thorax 
should glide backwards, it must ride over an eminence. The 
two upper extremities form a good portion of the superincum- 
bent weight upon the spine. The posture of the shoulder within 
certain limits is subject to normal variation. Departures from 
the normal posture of the shoulders produce an asymmetrical 
distribution of the weight of these extremities upon the spine. 
It has been demonstrated that weight falling obliquely upon 
the spinal column can produce a rotary lateral curvature. 
fBradford and Lovett, "Orthopedic Surgery," 2d edition, 1899, 
p. 94.) 

So long as this patient grew up with no bad postural habit 
and with fair health, with her ligaments strong enough to keep 
the thorax balanced, her muscles in good condition, so that they 
were used co-ordinately, the development of each one of these 
elements was a symmetrical development, and she was straight. 
But habitual posture placed the weight of the head, upper ex- 
tremities, and thorax upon the spinal column obliquely. Bad 
health, anaemia, kept her constantly tired, her ligaments and 
muscles weak, her bones soft. She acquired the habi^, when 
standing and sitting, when reading or writing, of holding the 
head to the right, of rotating the left shoulder backward, the 
right forward, and left hip up and forward, the right back- 
ward. As a result of this, the superincumbent weight fell 
obliquely upon the column in the direction of the arrow in 



184 TATEKAL CURVATURE OF THE SPINE. 

Fig. 19. In this picture the patient is photographed standing. 
The paper arrow stuck on the chest shows the direction of the 
force of the superincumbent weight. The posture with refer- 
ence to the spine was one of flexion forward and lateral flexion 




Fig. 19. 

to the left. Under this influence, acting through a number 
of years, the spine bent with the convexity of the curv^e to the 
right (in the dorsal region). Thus the bodies of the vertebne 
rotated to the right; and the ribs rotated and bent, too, until 
the parts of each horacic element under the superincumbent 
weight were acted upon in the direction of the arrows in Fig. 20. 



MICHAEL HOKE. 185 

AiTDW a represents the action of the slant hig force of the body weight upon 
each thoracic element from the fifth inclusive down. From this vertebne 
rotated in the direction of the arrow b; the spine, an*ow c. The right ribs 
were acted upon by forces (arrows) a and d; the left ribs, arrows c and b. 

The body weight acted in this manner for several years. Thus each thoracic 
element was by these forces changed from the symmetrical shape to the 
deformed in Fig 21. 

In the synmietrical element the two ribs (forces) are attached (applied) 







to the spine at analogous points on the sides of the vertebra*. Here in this 
deformed thorax, in these defoniied elements, all like Fig. 21, not only were 
the elements deformed, as shown in Fig. 22, but the direction of the applica- 
tion of the forces (ribs) to the spine was different on the two sides. The 
point of application of those on the left was anterior to the similar point of 
application of their fellows on tlie right; and the forces (ribs) were applied 
at differently inclined angles, which under the influence of weight must make 
the chest rotate to the right. 

The sum total of the changes in the elements produced the 
deformity seen in Figs. 2 and 19, standing, and Fig. 3, bending 
forw^ard. Thus the back to tlie left of the spine was sunken 
in from the fourth rib down; to the right of the spine the 
prominence of the ribs extended from fourth rib down ; the chest 
wall was flattened beneath the right axilla; a prominence was 
produced over the left costal margin and adjacent part of 
ribs in front. This combined skeletal deformity and bad post- 
ure gave the figure of the patient. 

The barbarous brace shown in Fig. 1 held her in this deformed 
posture, and by vicious pressure upon the thoracic wall increased 
every feature of the deformity. The photograph illustrates the 
harm that may be done by such gi'ossly ignorant application 
of apparatus. 



186 LATERAL CURVATURE OF THE SPINE. 

In the beginning the problem was not clear; but, with the 
hope that it would become clear, the effort for several months 
— May, June, July, and August — ^was to render the spine as 
flexible as possible. Exercises were given daily for three months. 
These were movements of the lower extremities, synmietrical 
extension exercises for the back, combined exercises of the legs 
and abdomen, with the intention of reducing the exaggerated 
lumbar curve, neck exercises, and arm movements. Suspen- 
sion was combined with manipulation of the trunk by the hands, 
in order by coimter-rotation (rotation to the left) efforts to 
stretch the contracted ligaments better. 

When the wiiter, standing behind the patient, grasped her 
pelvis at the left anterior superior spine with his left hand, and 
her chest wall over the prominence of the right side with his 
right hand, and. rotated the former backward and the latter 
forward, a much more corrected attitude could be assumed 
by the patient, — the back flatter, the thorax more directly over 
the hips, the depression shallower, the rib bump less prominent, 
and, when the hands were removed, the body slid obliquely 
to the right, and twisted to the right. When these counter-rota- 
tion efforts were made at intervals during the time the patient 
was exercising in the office, it made it easier for her to exercise 
in the more correct posture. In other words, when trying to 
stand straight, to flatten the back, to straighten out the curve, 
to hold the body directly over the pelvis, what opposed her ef- 
forts was the tendency to twist around the spine to the right, — 
torsion, — and in proportion to the degree this was corrected 
for her by the writer's efforts with his hands was she enabled 
to assume a better posture; and the reason she could not assume 
such a degree of improved posture alone was the fact that her 
own muscles lacked just as much power to rotate the body and 
spine back towards the normal posture as the writer put in his 
efforts to assist her. This was sufficient to make him "strain." 
Some appreciation of the task placed upon her muscles can thus 
be had. Using all his force, the writer was not able to twist 
the body much to the left. There was a great resistance to this 
effort. 



MICHAEL HOKE. 187 

The mechanics of this was as follows (it is most important to 
understand this clearly): — 

It was seen by examination that the width of corresponding 
intercostal spaces is the same in a normal thorax (fascia and 
intercostal muscles fill this). The same is true of the space 
between corresponding transverse processes, which means that 
the anterior costo-transverse ligaments between corresponding 
transverse processes and ribs are of equal length, balancing, 
behind, the anchorage of one element to another. Under the 
obliquely acting superincumbent weight each element from 
the fifth inclusive down had been deformed as above, the ribs 
on the left were crowded close together, narrowing the inter- 
costal spaces (shortening the fascia and muscles), narrowing 
the left inter-transverse spaces (shortening the anterior costo- 
transverse ligaments of the left side), and the tendinous attach- 
ments of the deep muscles of the back extending across these 
spaces from the vertebral spine out to the angle. The same 
structures on the right side of the spine were stretched. 

All the exercises could possibly accomplish was to stretch 
the ligaments, etc., on the left side, and to develop the muscles 
of the back. The counter-rotation efforts with the writer's 
hands helped to further stretch all the ligaments, and made it 
easier for her muscles to hold her straighter. The ligaments 
having been stretched, giving greater latitude of motion of the 
parts towards the normal, and the muscles having been toned 
up, a certain amoimt of rotation and lateral flexion could be 
corrected by her muscles. But the bone deformity of each 
element had not been changed in the least. The left rib of each 
element was still simken into the left of its vertebra as much 
as formerly. It has been shown that the ribs are props to the 
spine, that each rib is a force acting on the spine, that in a normal 
thorax, e^ch element being synmietrical and these ribs being 
of th^^ same size and applied to the spine in the same pfene, 
they have no advantage over one another. Here,^ however, 
the situation was different. As seen in Jig. 22, the Une of 
action of the left ribs (force applied to spine) were now all anterior 
to the line of action of the right ribs. In addition the left ribs 



188 LATERAL CURVATURE OF THE SPINE. 

were almost straight. Thus all the deformed left ribs made 
a "straight thrust" against the spine, the right ribs an oblique 
thrust. 

In attempting to coimter-rotate each element further, to 
correct the torsion, to change the shape of each element, the 
effort to rotate the spine in direction of y met rib 2, greater 
than y; for y was limited to the extent the patient could stand 
pressure and pain. (See Fig. 22.) 

The rib being unyielding, the result desired could not be ac- 
complished until z was weakened. This could not be done until 
z was severed somewhere, probably close to the spine. Uix)n 
this principle depended the only possible hope. 




_ -/-^^ 



The same story is told by photographs taken at the end of 
seven months' exercises. (See Fig. 23.) She is standing in the 
best posture she can assume. The head is held straight. The 
spine is straight from first cervical to the fourth dorsal, shoulders 
on a level, the left hip not very prominent, the contour of the 
left side more natural, the lumbar curve flatter, the spine less 
curved from the fourth dorsal to sacrum, the trunk vertically 
above the hips. The improvement above the fourth dorsal is 
permanent, for there was no bone deformity: below, except the 
increased flexibility, there is no permanent improvement. The 
improvement is postural entirely, due to a better relation of the 
elements to one another having been produced by the' exercises 
(stretching contracted ligaments and toning up the muscles). 
When the picture was taken, she was in a state of muscular ten- 
sion to hold the posture. Fig, 19 is a photograph taken two 
minutes after Fig. 23. See how the body has twisted to the 
right under the influence of obliquely acting body-weight until 



MICHAEL HOKE. 



189 



it came to a position of rest. The exercises toned up the mug- 
cles, increased their power, produced co-ordination, but no 
human being can or will stand, walk, or sit in a state of muscular 
strain. A position cannot be held which requires a constant 




FlO. 23. 

muscle contraction for its assumption. The improved posture 
in this case could be lost in a few minutes, and was, as 
shown in the photographs. Fig. 23 represents what would be 
the posture for a few minutes. Fig. 19 would be the posture 
the remainder of the day, so long as she sat or stood up. 
The bojie deformity of each element was still present, the de- 
forming forces still acting as strongly as before. Fig. 3 was 



190 LATERAL CURVATURE OF THE SPINE. 

taken a few minutes after Fig. 23. The body must twist to 
the right. 

The depression in the back to the left of the chest in 
front and below the left scapula (normally, a prominence 
making the shoulder glide forward), and the buckling backward 
of the ribs to the right of the spine in front of and below the 
right scapula (normally not so prominent and equal in elevation 
to th^ same area on the left, making the right arm glide forward), 
meant that in this case the left extremity must glide backward, 
and the right extremity forward, and the weight of these two 
extremities (a good part of the superincumbent weight) must 
of necessity act in an oblique manner upon the spine, and, as 
long as they acted thus, must they keep active a twisting force. 
This must continue imtil the shapes, cur\'es of the ribs in ques- 
tion, be restored to something like the normal. Nor could the 
head be balanced in position imtil the body beneath should be 
better balanced. The weight of each thoracic element must, 
too, be eccentric with reference to the spine (from the shapes 
of them). Each element would twist upon the spine to the 
right. Thus the whole thorax would twist. 

The question at once came up, Why not put the patient in some 
form of removable jacket, so that exercises could be taken, 
and preserve the upright position? That would have been done; 
but, unless the shoulders were put in the jacket, the position could 
not be held. When a jacket was put on up to the arm pits, the 
left ehoulder would slide backwards over it, the right shoulder 
forward, the prominence of the ribs on right side behind ap- 
peared increased by the thickness of the plaster. In other 
words, though not so badly twisted with apparatus as without 
it, the patient, even with apparatus on, presented a badly 
deformed appearance. 

The problem resolved itself into this: Each element, from the 
fifth inclusive down, instead of being symmetrical, as in Fig. 20, 
was now deformed into Fig. 21. Then each element from the 
fifth inclusive down must be changed into Fig. 20, or as near it 
as possible by some means. This could not be done by plaster: 
therefore, an operation must be devised. 



MICHAEL HOKE. 191 

In planning an operative procedure at this time, two things 
were dominant: first, to cut the ribs on the left side; second, 
to cut them without puncturing the pleura. The first could 
be done, and the second avoided, if the ribs could be success- 
fully shelled out of their periosteal covering at the site at which 
it was desirable to cut them. 

Six dogs were operated upon. The results of these opera- 
tions demonstrated that in operating upon dogs the following 
things were true: — 

First, after the skeleton of the dog's back had been exposed 
by incising skin and muscles, it was possible to shell a niunber 
of ribs out of their periosteum and to divide them each in sev- 
eral places, if so desired. 




Second, that the periosteum (pleura) on the inner face of 
the ribs is not so adherent to the ribs as on the outer face (a 
fortimate circimistance) ; that the pleural periosteum was at- 
tached firmly only to the lips of the borders of the ribs. 

Third, there was much danger of puncturing the pleura. 

Fourth, the pleura was pimctured several times, air was 
sucked in. The inrushing air was stopped by folding a piece 
of tissue over the place, and stitching back the periosteum over 
the rib. 

Fifth, where there was much air sucked in through the 
punctured pleiwa, the respiration became labored. 

Sixth, the hemorrhage from the periosteum and rib amoimted 
to nothing, not more than one or two clamps being required 
in several rib sections. 

Seventh, the best incision through the periosteum is an H- 
shaped incision — see Fig. 24— rather than only a longitudinal 
one, for the reason that, when the shaded areas a and b were 
reflected back, the remaining periosteal attachment on the outer 



192 LATERAL CURVATURE OF THE SPIXE. 

surface of the rib oflFered no resistance to stripping the inner 
face of the rib : whereas in the longitudinal incision troublesome 
resistance was offered. 

Eighth, there is no danger of injuring the intercostal arteries 
and nerves: they are reflected out of the way as the periosteum 
is detached. 

Ninth, evidently no pain follows the operation other than to 
be expected from any wound. The dogs breathe quietly and 
naturally. 

One dog died the night of the operation. It was not ascer- 
tained why he died. There w^as no hemorrhage at the operar 
tion, nor was his pleura punctured. Unfortunately, his body 
was immediately thrown out by the janitor before an autopsy 
could be made. 

Notes of Operation Done on the Cadaver. 

An incision wfus made throunjh the skin fat and fascia from a point a little 
to the left of the spine of the fourth dorsal vertebra downwards and outwards 
to a point a little below and external to the lower angle of the left scapula. 
A second incision was begim at the lower angle of the scapula, and carried 
towards the spine of the second lumbar vertebra. A smaU triangular area 
just below and internal to the lower angle of the scapula, bordered below by 
the upper edge of the latlssimus dorsi, above by the lower fibres of the trape- 
zius, and externally by the last inch or inch and a half of the p>osterior border 
of the scapula, was sought as soon as the skin incisions were made. By going 
through a thin plane of fascia here, the thoracic wall was exposed to view. 
It IS the only area on the back not covered by muscle. Then by blunt dis- 
section, using the fingers, it was very easy to lift up the trapezius and latis- 
simus doi*si muscles from the thoracic wall, exposing tlje ribs covered only 
by loose areolar tissue. By retracting these nmscles, without cutting them, 
the fifth, sixth, beventh, eighth, and ninth left ribs were accessible for opera- 
tion from the angle of the ribs to the attachments of the serratus magnus. 

To expose the entire side from the fourth rib down to the twelfth, it was 
necessary to cut the trapezius across its fibres for about two inches and the 
latissimus dorsi for about five inches. With this incision the entire left half 
of the back and the side of the thorax were easily accessible. The hand 
could be passed up into the axilla, and by retracting the shoulder outwards 
and forwards the ribs l)ciieath the scapula were accessible for op>eration. 

The rib from its angle to the head could not be op)erated upon. The ten- 
dinous fibres which attach the deep back muscles to the ribs phmge into the 
rib. These fibres could not be stripped off. There was no detachable peri- 
osteal membrane, such as covers the other bony part of the rib. The part 
of the ri})S tluit could be operated upon extended from the angle to the attach- 
ment of the serratus magnus. 



MICHAEL HOKE. 



193 



The knife was laid aside after the ribs were exp>osed to view. At a selected 
site the | — | shaped incision was made with the writer's periosteal elevator 
No. 1 (see Fig. 25) through the periosteum. With elevator No. 2 (see Fig. 25) 
the flaps a and b were rapidly stripped off the outer surface of the rib to its 
borders. 

Though rapid work may be done from this point on, it was necessary to 
use the most extreme care. With elevators No. 3 (right and left) the peri- 
osteum was stripped off the upper and lower borders of the rib to the inner 
lip. The operator must cling close to the bone with the edge of the instni- 
ment, scraping the bone. In this way puncturing the pleura was avoided. 




Fig. 25. 



Elevators No. 4 (left and right), with longer shanks than No. 3, were used 
to strip the inner face of the rib of the pleural periosteum. The pleura and 
I>eriosteum are here the same thin tissue: one can see through it. 

The periosteum was attached to the inner lip of the upper and lower borders. 
Between these lines, or the imier face, it lay in close contact with the rib, 
but was not attached, as the periosteum is, on the outer surface of the rib 
and at the borders. It would seem tlint nature had prepared the way for 
this operation; for, if the pleural periosteum were as firmly adherent as the 
outer periosteum, it would be practically impos-sible to do the operation on 
account of the time it would take to safely shell out the ribs. 

After the section of rib had been shelled out, the operator could do as he 
wi.shed with the cleaned bone without entering tlie pleural cavity. 

The intercostal blood vessels and nerves were not injured in the perios- 
teal dissection. The instrument was always between them and the bone of 
the rib. The periosteum could be stitched over the rib, if so desired. 



194 LATERAL CURVATURE OF THE SPINE. 

InstrumeiUs for the Periosteal Direction. — A number of instruments were 
designed and then discarded. Finally, the ones shown in Fig:. 25 were 
designed, and proved to be perfectly satisfactory. Indeed, it would be im- 
possible to do the periosteal dissection with facility without them. 

The handle of each, except No. 2, is a little bigger in diameter than a pencil. 
In using them, they are held in the hand just as one holds a pencil in writing. 
Thus one obtains the advantage of the hand's best tactile judgment in strip- 
ping the rib where this procedure is most difficult. 

No. 1 has a cutting edge, rounded and sharp. It is used to make the incision 
through the periosteum. Its advantage over a knife is that it has no point 
and is much heavier. Its weight necessitates less pressure to be made in 
making the periosteal incision, thereby decreasing the danger of the instru- 
ment slipping and cutting into the lung cavity. 

No. 2 through its curved beak enables one to apply the power of stripping 
effort directly upon the bone. Here, again, the danger of slipping is prac- 
tically obviated. The beak is one-half inch wide, so that it takes only very 
few strokes to bare the outer siuface of the rib. 

No. 3 (right and left) arc shaped like golf sticks. They are used to strip 
the periosteum from the borders of the ribs. The curve of the shank is such 
that without changing the postiu^ of the operator's hand the instrument 
glides over the borders of the rib. 

No. 4 (right and left) have longer shanks than No. 3, and are used like 
No. 3, only, by virtue of their long shanks, one is enabled to strip the inner 
face of the rib easily. 

In asing Nos. 3 and 4, they are handled as one uses a pencil in making an 
up and down stroke, moving the fingers chiefly, the wrist a little. Note 
the thickness of the shank and its bevelled character. By hugging the bone 
with the scraping edge, this thick bevelled shank depresses the membrane 
from the bone, decreasing the danger of cutting through. 

No. 5 is a rib punch with which one can punch a hole in fragments if it be 
desired to wire thejii. 

No. 6 is an extremely useful costotome. The cuttuig part of the instrument 
is at right angles to the handle. 

December 3 the patient returned to undergo the first operation. Her con- 
dition was good. 

Fig. 23 shows the best position she could hold for a minute or two, by 
much tension. This position she could not hold longer. Fig. 19 shows the 
body shape as she stood naturally, as she walked. In a jacket the deformity 
was still just as distressing in appearance. Fig. 3 shows the patient benduig 
forward, the bone deformity of the thorax still present. These photographs 
were taken within a few minutes of eaeh other. The.v show that no result 
but flexibility had been obtained, that the structural deformity of the chest, 
as above explained in detail, forced the trunk from its weight to twist to the 
right. 

First Operation J Dec. 6, 1902. — ^Usual preparation for operation. Ether. 
Rubber gloves worn by operator and assistants. Patient lay on her stomach. 
Beginning at the spine of the fifth vertebra, the incision extended down- 



MICHAEL HOKE. 



195 



wards and outwards to a point a little below and external to the inferior 
angle of the scapula. The second incision extended from the scapular angle 
towards the twelfth dorsal vertebra. The triangular area was exposed; 
with the fingers the latis^imus dorsi and trapezius were separated. Long 
clamps were applie<i to the trapezius perpendicular to the direction of its 
lower fibres. The trapezius was divided between these clamps for two inches. 
The rhomhoideus major was coextensively cut. By retracting the skin and 
muscles and holding the upper extremity forwards and outwards the skeleton 
of the thorax was exposed, tlie ribs glistening beneath a thin layer of areolar 




Fig. Z. 



tissue. Tlie fifth, sixth, seventh, and eighth ribs were selected for operation, 
because, the.se being rotated forward, the most of their normal curve having 
been straightened more than the others, they corresponded to the deepest 
sunken area in front of and just below the tip of the shoulder blade; because, 
as long as that, area was sunkeii in, the plane of the chest wall would be such 
that the left shoulder must glide backwards towards the spine; and because 
the position of these ribs and their attachment to the spine opposed structu- 
rally the counter-rotation efforts. If the sunken area were filled in, then the 
shoulder must glide forwards and its weight would be properly applied to 
the spine, and that much obliquely applied superincumbent weiejht overcome: 
if the area were filled in, each element so oi>erated upon would be nearer 
the s\'mmetrical shape, and the weight of such element operated upon would 
fall less obliquely «pon the spine. If by the operation the line of action of 
force z were changed to «' (Fi^. 22), then the forces of the elements (ribs) ap- 



196 LATERAL CURVATURE OF THE SPINE. 

plied to the spine would be more nearly in equilibrium, rib resistance to counter- 
rotation would be overcome, "rotation flexibility" would be produced. From 
these things the trunk would be better balanced. 

The incision described above was made in the periosteum. The i>erio8- 
teum or the outer surface of the rib for one and a quarter inches was peeled 
off with elevator No. 2, as near the angle as possible. 

Fig. Z shows on cadaver the method of stripping rib of its periosteum. 



g 



1 



Fig. 26. 

Elevator No. 1 was used to strip the inner surface of the rib. (In the dog 
operations these two instruments were used, and sufficed for the task. The 
first operation on the patient was done with these two periosteal instruments. 
One can imagine the discomfort the operator exp>erienced when he found the 
ribs so crowded together that the blade of Xo. 1 could hardly be used on the 
inner face of the rib. It was extremely difficult to strip the ribs' inner surface 
with a straiglit mstrument without cutting through the pleura with each 
stroke. But it was finaUy successfully accomplished.) There was very little 
bleeding, which stopped as soon as the i>eriosteum was entirely loosened. 

After the desired segment of each rib had been shelled out of its periosteum, 
strips of gauze were oassed under the ribs. The ribs were then divided by 




bone forceps between tlie gauze strips. A smaU piece was cut off the frag- 
ments distal to the spine, as shown in Fig. 18. An assistant lifted the cut 
ends by tniction on the gauze strips, preventing possible tearing of the pleura 
by the cut ends moving with the respiratory effort. Notches were cut hito 
the upper and lower borders of each fragment. (See Fig. 26.) 

An a.ssistant then made counter-rotation pressure upont he prominence on 
the right of the spine. The distal fragment was lapped over the fragment 
nearest the spine. The ends were wired with silver wire catching in the 
notches. By this rotation and overlapping of the rib fragments the change in 
each element was as seen in Fig. 27. 

Examine tlie photograph (Fig. 32) to see the actual change. 



MICHAEL HOKE. 197 

After the fragments were wired, the i^eriosteiiin of three sef^ients was 
stitched back with fine silk. The periosteum of the fourth segments could 
not be stitched, owing to retractiou and contraction of the intercostal mus- 
cles. 

Two mattress sutures of silk were used to reunite the divided portion of 
the trapezius. Three vessels were tied in the operation. The skin was sewed 
up with a subcutaneous stitch. Patient was put in a plaster jacket. 

It took three hours and thirty minutes to do the operation, from tlie mo- 
ment she was placed on the table until she was taken off. 

There was a good deal of shock. This shock was produced by several things: 
prolonged anaesthesia, lyuig on the belly, and the forceful effort to counter- 
rotate the spine after the ribs had been cut, and the patient's lack of reserve 
heart power. 

As soon as the patient was put to bed, lying on her back, she rallied, and 
was soon in good condition. 

Notes from Bedside Chart. 

First Day. — Badly nauseated, vomiting, pain in abdomen; highest tem- 
peratiwe, pulse, and respiration, 99i, 136, 50. 

Second Day. — Badly nauseated, suffered much from abdominal pain ; high- 
est temperature, pulse, and respiration, 100, 134, 34. 

Third Day. — Nauseated, nervous; highest temperature, pulse, and respira- 
tion, 100, 118, 26. 

Fourth Day — Some nausea and vomiting, better, quiet; highest tempera- 
ture, pulse, and respiration, lOOj, 120, 20. Menstruating. 

Fifth Day. — Pain in stomach; highest temperature, pulse, and respiration, 
99f , 108, J>0. Ner\ou8. 

Sixth Day. — Menstruation ceasing, slept well, comfortable; highest tem- 
peratmre, pulse, and respiration, 100, 110, 18. 

Seventh Day. — Pulse, 87; temperature, 99; respiration, 18. After the 
seventh there was no discomfort. At no time was there any indication of 
pleural friction. 

Fourteenth 7)ay.— Stitches in skin were removed. Healing perfect. In 
the photograph the scar appears wide: as it stretched. In the fourth 
week the jacket was changed and the patient was allowed to go home. 

Jan. 29, 1903. — Returned to-day for jacket. The area operated upon is more 
filled in, exactly how much it is impossible to know. The left shoulder does 
not slide backward so ea.sily as it did before the operation. There is not such 
a great tendency for the bod}' to rotate to right. There is no change in the 
right side that one can estimate with the eye. The body seems better bal- 
anced. The curve of the spine in the mid-dorsal region (a.s .<lK)wn by spines 
of vertebrse) is increased, as would be expected from the mechimics of counter- 
rotation. Sent home in a jacket. 

Feb. 15, 1903. — Patient returned to-day for second operation. In the 
first operations, difficulties were encountered which would make the repeti- 
tion of that procedure not advisable. The time consumed was too long, 
there was too much shock. Could another means be devised to shorten time 
and facilitate the operation? 



198 



LATERAL CURVATURE OF THE SPINK. 



The other periosteal instruments, Nos. 3 and 4 (right and left), were, 
after having tried and discarded many models, found to make the stripping 
of the periosteum easy after prat'tice, so that the danfirer of gouig through 
the pleura was minimized and the dependent slowness of the procedure done 
away with. 

Fig. 28 shows a section of a lamb*s thorax with the ribs intact: they are 




Fifl. 28. 



stiflf and unyielding. Fig. 29 shows the same with ribs operated upon in 
three places. At each site the rib was not quite severed, all birt the inner 
sheU havnig been removed. 

Fig. 30 shows the flexibility of the same side after the operation had been 
performed. 

The degree of flexibility after the operation in animal subjects varied with 
the toughness of the ribs and the thickness of the shell left. It must vary 
Ln the hiunan thorax, and in different parts of the same thorax. 

The rational thing at this second operation would have been to operate 
upon the ribs of the left side, which were not touched in the first operation, 



MICHAEL HOKE. 



199 



left untouched at that operation because the writer did not feel like exposing 
the patient longer. 

But it was feared the patient might not consent to the third operation, 
which it was seen at this time would be necessary. The hump on the right 
side of the sphie was still present, and projected more with a jacket on than 
without a jacket. If she should not fail in courage, he hoped to leave her with 




Fio. 29. 



much of this hump diminished in size. Therefore, he determined to oj>erate 
upon the right ribs at the second operation. 

F^, 20, 1903. — Second operation. Ether. Patient lay on left side. 
Gloves worn by operator, assistants, and nurses. 

It was pbumed to make two rib sections, as shown in Fig. X from each 
rib from the fifth to the tenth inclusive, along the lines shown in Fig. 18. The 
incision made is shown in Fig. 31. The same procedure was done to ex- 
pose the ribs as was done on the cadaver and at the first operation, only 
the second incision was longer, and a part of the latissimus dorsi was divided 
across its fibres, as well as a part of the trapezius 



200 



LATERAL CURVATURE OF THE SPINE. 



Twelve rib sections were made. The average length of time for each sec- 
tion (stripping tlie periosteum and cutting one section of the rib, leaving' the 
inner table) was three minutes and ten seconds. The periosteum was [not 
stitched back over the gap. The cut in the trapezius was 1^ inches long only. 
The position while operating imder the shoulder blade was cramped. The 
latiasimiis dorsi was cut across its fibres five inches. The incisions [in the 
trapezius and latissimus dorsi were reunited by mattress sutures. Subcu- 
taneous skin suture was used. 




Fig. 30. 



Prior to the operation a cast of the back was taken, as the patient bent 
forward. The hump to the right of the spine was cai'\*ed from the plaster 
reproduction of the back made from the cast, and the depression to the left 
was filled in with plaster. Tlien a plaster ca^t of this earned reproduction, 
of the back only, was made. When the operation was finished, while still 
under ether, the patient was laid back down in this cast, and strapped to it. 
A fracture of a number of the ribs was produced. A plaster jacket was ap- 
pHed to the patient lying in this splint, including the splint. 



MTCHAEJ. HOKE. 



201 







Fig. 31. 



202 LATERAL CURVATURE OF THE SPINE. 

Two hours and three minutes elapsed from the moment the incision was 
begun until the sewing was finished. 

Thirteen minutes were consumed in putting on the jacket. The pleura 
was not punctiu^ at all. There was no shock, no embarrassed respiration 
at any time during the operation. The operation was performed in a space 
of time which could not be regarded as objectionable, and as many ribs were 
operated upon as will ever need attention in any case. This demonstrated 
that the procedure could be done successfully without danger to the patient 
and in a reasonable length of time. 

Fig. X shows the mechanics of what was done to each element, and how 
pressure upon the prominence after the elements had been operated upon 
would change the shape of each element, the idea being to change the shape 
by the operation, then to hold the patient in a jacket until new bone should 
fill in the gap in ribs, thus producing finally a more symmetrical and a solid 
set of elements. The attempt, one sees, was to flatten the prominence beneath 
the right shoulder, to cliange the plane of the thorax at that point, so that 
the right shoulder would glide backwards instead of forward, and thus make 
the two shoulder blades level. 

An examination of Fig. 32 shows that the fifth and sixth ribs did not fract- 
ure. Notice liow prominent they are. and that from that prominence (dotted 
line at the foot of it) the hump has been symmetrically reduced to the twelfth 
rib. With reference to reducing the hump in the fifth and sixth ribs close 
to the spine the operation was a failure. But, even with partial change 
in the fifth and sixth elements, the change produced in the other elements 
balanced the body better and the right shoulder was easier to hold back, 
though the tendency for it to glide forward was not entirely overcome. An 
effort to counter-rotate was still resisted by the ribs on the left side, untouched at 
the first operation. The patient's back was excoriated by tlie pressure of the 
plaster. This produced discomfort. Otherwise there was nothing wortliy 
of note in the convalescing period. No such degree of flexibility produced 
by operating upon the lamb's ribs was obtained here, for the reason that in 
this patient the outer shell of bone beneath the periosteum was much thicker, 
and therefore more resistant. Evidently, the operator's desires co\ild not 
be partly trusted to pressure after the skin incision is sewed. What- 
ever might be desired must be done completely with the costotome while 
down upon the ribs. The fractures sliould have been made complete where 
they were wanted. 

June 23, 1903. — Patient returned for the third operation. Her general 
condition was good. This operation was performed on the 26th of last June. 

Ether. Gloves. Patient lying on right side. At this operation the tech- 
nique in getting to the ribs and in shelling them out was the same as in the 
second operation: hence it is unnecessary to go into details. In this third 
operation the twelfth rib was fractured during the operation by the fingers 
after the section of rib had been cut out in one place, the eleventh in two places, 
the tenth in three places, the ninth in three places, the eighth in three places, 
the seventh in two places. (The sites operated upon on the seventh and 
eighth were external to the section made in the first operation.) These fract- 
ures were incomplete, "green stick," except at one place on the eighth rib 



MICHAEL HOKE. 



203 



and one place on the tentli. The pleura was punctured once in this opera- 
tion, the only time in the three operations that this was done. A little air 
sucked in, — ver>' little, — the suction of air stopped by folding tissue over 
the rib and stitching it there. It took one hour and forty minutes to do the 
operation from the first stroke of the knife to finishing the dressing. The 




F'lO. 32. 



day before the operation the pins of the autlior's apparatus, used in apply- 
ing the jackets, were set in just the position desired, so that the proper press- 
ure could be made. As aooTi as the operation was finished, the patient was 
transferred to the apparatus. T!ie banda^ices had been put in water a few 
minutes before and were ready for use. The application of the jacket took 
fifteen minutes. There was no shock. 

Note, July 6. — Ten days since operation. To-day first dressing was made. 
Union is perfect. Stitches removed. Depression in back much filled out. 
Patient can move herself somewhat ^nthout pain. Condition perfect. Looks 



204 LATERAL CURVATURE OF THE SPINE. 

better than before she went into the operation. She has had no pain sinre 
the operation except a little belly-ache. The highest temperature was 99}; 
highest pulse, 126. Temperature was normal after the third day. After 
the dressing was made, the patient was put in the special apparatus and a 
jacket applied without use of ether. Ether was not used at any time except 
when an operation was performed. It is perfectly easy to rotate the chest in 
any direction with the hands. Fig. 34 shows the apparatus for application 
of the jacketji the patient having been left on the frame long enough to make 
a photograph. The writer has called this his apparatus for lack of another 
term of identification. The principles are the same as formerly in use, but 
the details of construction are different. A jacket can be applied with the 
patient lying on her face or on a hanunock stretched on the gas-pipe frame, 
the adjustable steel arches can be placed above and below, or the patient 
can be placed on her back, her hips and shoulders restmg on padded boards, 
as shown in the illustration. The pins, large screws, may be slid along 
the steel arches to any position desired. The screws, since they revolve in 




Fig. 33. 

a vertical plaiip, can be placed fo tliat pressure may be made uj)on any part 
of any element at any angle desired. In the illustration a padded steel piece an 
inch wide, and long enough to extend acroas several ribs, was placed beneath 
the angles of the right ribs; and the two pins below press upwards at points 
a half -inch from the ends of the board. In this demonstration each element 
from the seventh down was subjected to the forces acting as shown in 
Fig 33. 

^Vith the flexibility produced by the last operation it u^s possible to put the 
patient in this apparatus in such a position that the back was flat and the front 
part of the chest perfectly symmetrical. 

In a normal thorax the spine is straight, each element is a symmetrical 
figure, and eacli element is balanced upon the spine. Thus the whole thorax 
in a normally developed person is constructed so as to be balanced. Note 
that the muscles of the trunk are arranged to control the movements of a 
balanced figure. Were the elements joined behind as they are in front, there 
would be no flexibility. The ligaments, spinal and costo-spinal, prominently 
the anterior costo-transverse ligament, the tendinous attachments of the 
deep muscles from rib to rib, and transverse process to transverse process pre- 
serve the poise of the body witliin the limits of motion possible. The body 
cannot bend further than the ribs permit. Within this limit the ligaments 
mav limit the motion. The muscles execute the motion. The relaxation 



MICHAEL HOKE. 



2()5 



of a set of muscles can throw the spine out of balance. Thus undue tension 
is put on the ligaments of the same side. Ligaments stretch from constantly 
bearing strain. The constant contraction of a muscle or group of muscles 
and the relaxation of the group of the opposite side cannot carry tlie body 
in a certain direction further than the ribs will permit. If the body bends 
beyond the natural limit, the ribs bend. 

The chain of causes here and in all lateral curvature cases not caused by 
disease must be this: a group of muscles tires easily, the weight falls obliquely 
on the spine, rotation and lateral bending of the spine begins, the ligaments 
stretch, continued obliquely acting weight causes the spine to rotate further, 
the ribs to go forward and straighten on one side, to rotate backwards and 
bend backwards on the opposite side, so that finally one has to contend with 




Fig. 34. 



weak muscles, contracted ligaments, fascia, and tendons on one side, the same 
stretched on the other side, and a deformed thorax, as above, — the expression 
of the sum of the deformities in the elements composing it. Thus contracted 
ligaments and soft tissue on one side of the spine form one group of condi- 
tions to be treated, the same structures stretclied on the other side a second 
group of conditions to be treated, the weak muscles a third condition, and, 
last and most difficult, the deformity of each bony element, as descril^ed above. 

Exercises as a means of developing muscle, to stretch ligaments, to build 
up the constitution, to produce a poise sense, are most valuable. Nothing 
else can take their place for these purposes. With jackets one may, if the 
thorax is put under the proper pressure conditions, obtain correction of bone 
deformity if the ribs are very flexible and the ligaments not contracted, the 
correction being trifling or considerable, depending upon how soft the bones 
may be and how relaxed the ligaments may be. 

Hitherto, since no other means was available, exercises and jackets have 
been applied to cases where they could have no influence upon the bony 
structure. 



206 LATERAL CURVATURE OF THE SPINE. 

In a case with osseous deformity, even after the ligaments, etc., have been 
stretched and muscles developed, the flattened and anterior displaced ribs 
are obstnictions to rotation and covnter-rotation of the spine, hence obstruc- 
tions to straightening the spine as well as being a part of the deformity of 
the elements. 

This operation makes it possible to change bone deformity that cannot be 
affected by plaster. It is thus to be used in the vast majority of cases, — 
the cases that are not simply postural. 

The result in this case must be about as clear to those who examine the 
photographs as to the writer. The case was one of severest cur\-e and osse- 
ous deformity. Thus the severest possible test to the surgical procedure 
has been tested in the first case so treated. The writer is frank to say that 
the best possible result has not been obtained in this instance. If he could 
go over this again, he would do to all the ribs in the left side from the fourth 
inclusive down in one operation as was done to the ribs operated upon in the 
third operation. He would then, when the patient was in proper condition, 
operate upon the right side after the same manner done in the second opera- 
tion, only he would do more and not depend upon the pressure of the jacket 
(put on immediately after the wound was sewed up) to produce the rib fract- 
ures. The above case is the only one ready for this semi-final report. 

In Fig. 2 the bad deformity is partly postural and partly structural. In 
Fig. 23 the postural element (dependent upon contracted ligaments and 
niuscles on the left side, and stretched ligaments and lax muscles on the 
right side) is gone, but the patient could not hold that improvement. (See 
Fig. 19, taken two minutes later.) Nor could the ^Titer hold it for her without 
keeping her in plaster, including the shoulders, — a horrible possibility to a 
woman; and, even with such a jacket on, the projection of the hump would 
have been exaggerated by the thickness of the plaster. The hmnp and the 
flattening were still there. (See Fig. 3.) 

Fig. 31 shows her upright posture August-, 1903, after the three operations. 
The photographs were taken after she had been standing about ten minutes. 
The difference had been produced by changing the shapes of the elements, 
balancing the thorax better by this change. Fig. 32 shows the patient bend- 
ing forward after the three operations. Contrast Fig. 3 with Fig. 32. 

The spine is not straight in the upright postiu-e, but it is straighter and the 
body outline is far more symmetrical. The posture of the upper extremities 
is vastly nearer the normal, and to a corresponding extent is the deforming 
force of their obliquely acting weights incident to their former positions cor- 
rected. When the patient lies prone, the .spine is straight. 

When standing with a light jacket on, very little deformity is perceptible. 
The body is very flexible now. Since the body is so flexible, she will be im- 
proved more by jackets put on, with the thorax under the proper pressure 
conditions. 

Since the result is not perfect, she would relapse to a certain extent with- 
out a jacket. The writer does not know how far she would relapse without 
a jacket. It would be interesting, but not fair, to find out. The writer does 
not believe it is possible for one to make such a defonned thorax perfectly 
symmetrical again. 



MICHAEL HOKE. 207 

The field for the operation's best usefulness must be with the great major- 
ity of cades in which a bad figure is dependent upon the deformity of a fewer 
number of elements than were deformed in this case. 

Correction jackets will be worn by the patient, changed once a month, for 
a while. Then a light removable jacket will be worn, so the patient may 
exercise (simple extension exercises) daily. 

In the examination of lateral curvature cases with osseous 
deformity one will always find the ribs flat on one side and prom- 
inent on the other. The broad mechanical principles of this case 
are operative in all osseously deformed cases, but there must 
be an infinitely varied detail, for the curve of the ribs and their . 
angles of inclination to the spine mean, if abnormal, the appli- 
cation of deforming forces to the column and thorax. If one 
operates, he does so not for disease, but to correct faulty mechan- 
ics and deformed anatomy. Thus, given a patient who is in 
physical condition for the operation, the result nmst depend 
upon the operator's interpretation of the forces with which 
he is contending and the accuracy with which his remedial 
procedure is executed. 

To the writer it seems fair to state that in the future lateral 
curvature with osseous deformity must be treated as follows: — 

(1) Exercises must be taken, in order to do away with all 
contraction of ligaments, fascia, and muscular resistance to 
flexibility, and to build up the general health. The writer 
thhiks that all the movements of the trunk must be executed 
in the exercises, regardless of the influence of such exercises 
upon the rotation of the vertebrae, flexibility being the sole 
object. 

(2) The flattened side of the back must be operated upon so 
that side forces (ribs) applied to the spine may be so weakened 
and the ribs made so flexible that the plane of the thorax be- 
neath the shoulder may be changed to as near the normal as 
possible, the flat ribs recurved towards the normal, and the 
resistance to rotation reduced or destroyed. 

(3) Then a series of jackets must be applied, using the prom- 
inent side as a point at which to apply pressure to obtain counter- 
rotation. These jackets are to be applied until the bone-union 
in the ribs is perfectly firm. 



208 LATERAL CURVATURE OF THE SPINE. 

(4) The curves in the ribs on the prominent side must by 
operation be restored to as near the normal as possible, in order 
to do away with the prominence and to restore the natural plane 
of the thorax beneath the shoulder. The accomplishment of 
2 and 3 better balances the thorax. 

(/>) A series of corrective jackets must be applied imtil the 
bone-union in the ribs is firm and all the correction posdble 
obtained. 

(6) A removable jacket and daily exercises. How long this 
jacket should be worn must depend upon the case. 

At some time in the future the writer will make another 
report upon the condition of the patient at the time of such 
report. 

It is not often that one witnesses the cheerful courage this 
yoimg lady showed in submitting to an untried operation which 
in this, the first instance, seemed to the writer full of possible 
difficulties. Hence, in writing the account of this case, it does 
not seem malapropos to mention one's appreciation of a high 
courage which expressed itself in a resignation to and confi- 
dence in the operator's plans.* 

•"Operative interference by reHection of tlie ribs has been iierformed twice by 
HofTa on patientH, and is said by him to liave been suffeested by Volkmann in 1899. 
but not i>erformed by him on the living patient" {Zeitffchr. fur orth. Chir., 1896, 
p. 4()1). 

ShaflFer advocates a new operation for the cure of rotar>' lateral curvature 
wliirh he had performed on the cufUiver. Amerlcun Medico-Surgical Bulletin, ^9,\\, 
1, 1SSJ4, 1), r.i, and Feb. 15, 18J»4, p. 'i,***.. 



ABSTRACTS. 



SCOLIOSIS. 

73. Zuppiaget'B Scoliosis Tbeoiy. Zeitsehr. fiur orth, Chir,, xi. 280. 

H. Zuppinger's theory is that pressure against the side of the thorax an- 
teriorly will produce a scoliosis, and finally also a twisting of the vertebrie. 
He bases his theory upon a large niunber of observations and measurements 
of normal and abnormal thoraces. He reports the case of a eirl who a year 
before was not scoliotic, but who has since then worked with ner right hand 
extended, at the same time leaning against a horizontal iron bar. She now 
presents a distinct costal hump anteriorly on the left side, posteriorly on the 
right side; the sternum deviates toward the left: the doreid spine is convex 
toward the right, the lumbar spine toward the left side. Treatment based 
upon his theory produced a marked change in ten weeks. — H. A. WxUan, 
Am, Med. 

74. Pathogenesis of the Scoliosis of Childhood. Zeilsehr. fur otih, Chir,, 

xi.383. 
Mechanical theories mav explain some of the cases of scoliosis, but no 
one theory can explain all of them. The fundamental condition must be 
sought for in a disease of the vertebral column. C. Deutschlander points 
to V. Recklingshausen's description of infantile osteomalacia. It is not 
a rachitic process, but one of softening and melting away, due to congestion 
of the bloodvessels. Anomalous blood-vessel waEs and mechanical irrita- 
tion due to increasizi|g pressure are the predisposing factors. The process 
once begun will continue itself, due to the decreasing ability of the spinal 
colunm to support the weight of the body. Ck)exi8ting deformities, as flat 
foot, genu valgum, etc., are a further expression of the disease. — H, A. WtUon, 
Am. Med. 

75. The Mechanics of Lateral Curvature as Applied to the Treatment of 

Severe Cases. By R. W. Lovett. Translated into German with a 
"Nachschrift" by W. Schulthess. Zeiischr, fUr arth. Chir., Bd. XI. 
Heft 4, 1903, pp. 827-855. 
In his "Nachschriff Schulthess urges the importance of Lovett's studies, 
but emphasizes the danger of inferring corrective results from posture in scoli- 
otic cases based on studies of behavior of normal spines. — G. W, FitZf Boston. 



SPINE. 

76. The Localisation of Osteomyelitis in the Lateral Parts of the Sacrum 
and its Relation to Growth. By Gross. Deutech. Zeit. fur Vhir., 
Ixviii. 95. 
G. reports six cases of this unusual affection. Points out its exclusive local- 
ization in the lateral parts of the bone. Shows anatomical preparations 
to prove that the growth of the sacrum takes place principally in the lateral 
paxts of the three upper segments. Attempts to show a causal relation be- 
tween this and the occmrence of the infection in this place. Involvement 
of the spinal canal was observed in only three of the cases found in the Ut- 
erature. Trauma is not considered important in the etiology The mortal- 
ity of the disease is great. Two forms, light and severe, are distinguished. 



210 ABSTRACTS. 

The frequent occurrence of pelvic abscesses makes the prognosis erave in 
all cases, however. The albuminous form of the disease nas been observed. 
A, H, Freiberg, Cincinnali, 

77. Affections of the Cauda Equina in Consequence of Tuberculosis of Ad- 
joininf^ Bones. By M. Bartels. MiUeiiungen a. d. Grenzgebieten dor 
Med. u, Chir,, xl. 1617, Jena. 

He reviews two cases personally observed and one other. If the tuber- 
culosis develops secondarily to a tuberculosis of the sacro-iliac synchondrosis 
and the adjoining bones, the nerve symptoms usually locate it. He considers 
surgical measures justified when the vertebrae are not affected and the symp- 
toms indicate compression b^ the upper part of the sacrum. When only 
the lower part of the sacrum is involved, he thinks little is to be gained by 
operation. — Ahst. Jour. Am. Med. Ass'n. 

78. Chronic Ankylosing Inflammation of the Spinal Column. Zeit. /. klin. 

Med.f xlix. 
V. O. Siv^n claims that under the name of spondylitis deformans are in- 
cluded several hetero^neous diseases. There are two main forms: in one 
the intervertebral cartilages are affected, and in the other the vertebral arches 
are the primary seats of disease. Four cases are reported belonging to the 
latter class. In all of them the small joints of the spinal column, together 
with their ligaments, were attacked by an inflammatory affection, which 
finally led to complete ossification and ankylosis of the joints. The disease 
process differs from ordinary arthritis deformans in being inflammatory in 
nature and in not being constitutional in character. — Abet. Am. Med. 

79. Spinalgia as an Early Symptom of Tuberculous Infection. By J. Pe- 

truschky. Miin. med. Woch., March 3, 1903. 
J. Petruschky is of the opinion that tuberculosis of the bronchial glands 
always precedes pulmonary tuberculosis. He quotes several vei^ strik- 
ing instances of advanced glandular disease, associated with pulmonary 
lesions so slight as to be without symptoms, and advances a theory to show 
how the tubercle bacilli reach the glands primarily As a verv early symp- 
tom of bronchial gland tuberculosis, he mentions spinalgia, '^tenderness of 
definite vertebral spines to pressure." The following symptom-complex is 
usuaUy present: 1. Several spinous processes are tender to touch, while the 
others are not at all: this tenderness increases with repetition of pressure. 
2. The painful spines are usually somewhat depressed. 3. The processes 
are usufuly broader, softer, and more elastic. 4. Thev are usually included 
between the second and seventh dorsal vertebra. The tuberculin reaction 
is necessary to settle the diagnosis beyond a doubt. In 79 cases of spinalgia 
the tuberculin reaction was positive in 77 cases, and only 14 of these had tuber- 
cle bacilli in the sputum. In advanced cases the symptom is ri^y present. 
It must not, however, be considered a pathognomic sign, but only a link in 
the chain of symptoms. — Abst. Am. Meet. 

80. Tuberculosis of the Spine. By J. E. Goldthwait. B. M. A S. Jour., 

Sept. 24, 1903. 
J. E. Goldthwait gives a statistical analjrsis of all the cases of tuberculosis 
of the spine which have appeared at the orthopedic department of the Carney 
Hospitu during the eight years previous to 1902. No patients under twelve 
years of age were treated. In aU there are 108 patients, of which 62 reported 
more or less regularly for treatment. Of this number (62) 41 were under 
thirty, and In 21 the disease had existed for from six to twenty years. In 
20 cases there was abscess. Of this number 8 died and 4 are at present in 
poor condition. In 11 cases there was paraplegia, and of this number 2 died. 
Of the 62 patients, 11 died, and in nearly all, death was due to the extension 
of the disease locally or to some other part of the body, the average time 



ABSTRACTS. 211 

between the onset of the disease and the time of death bein^ four yean. 
Attention is caUed to the fact that the eases studied were entirely hospital 
patients, fiving for the most part under poor hygienic conditions. A similar 
number of private cases studied would probably show more favorable results. 
Abgt. Am. Med. 

8i. Farther Observationa on Cervical Dislocation. By G. L. Walton. 
B. M. A S. Jour., cxlix. 17, 445. 

Cervical dislocation is not a mere medical curiosity, but is likely to i4>pear 
in the practice of any physician. Walton has seen at least sixteen cases. 
Traction is of no aid m reduction, in fact may hinder it by lessening the ef- 
fectiveness of the necessary fulcrum. In 1899 Walton proposed (torso-lat- 
eral flexion and rotation. Two cases have been reduced by this method at 
the Massachusetts General Hospital since that time, one by Dr. Beach and one 
by Dr. Mixter (the latter a case of six months' standing). In the other cases 
coming to Walton's knowledge since his previous communications two spon- 
taneous reductions took place during sleep and three during the etherization 
preparatory to oi>eration. One of these cases resulted from turning the head 
suddenly in running round a comer, one from a football scrimma^, one was 
produced in brushing the hair with military broishes, one by a railroad acci- 
dent, the rest by falls. 

The side of dislocation may be always determined by the rotation of the 
head, the face being turned away from the side of the displaced vertebra. 
If the process has supped down into the intervertebral notcn, the head will 
be beta toward the injured side. If it has been caught at the crest of the 
process below, the head will be bent in the opposite direction. 

For reduction the patient should always oe etherised and placed in the 
sitting position. Suppose the left articular process is displaced, and the 
patient is facing north, the head must be first tilted south-east, rotated shghtly 
with the face to the right, then rotated back to place. 



BONES AND JOINTS. 

8a. Syphilitic Joint Inflammations. By Borchard. DevUeh. Zeit. fur Chir., 
hd. 110 
Borchard divides luetic joint diseases into primary and secondary. The 
former may arise during the secondary or tertiary stage. In congenital 
Bfyphilis we may have both, the latter following inflammation of the neigh- 
bioring pmosteum and bone. Either may be acute or chronic. The acute, 
characterized by hydrops and swelling, is nothing more than synovitis, due 
to syphilitic poison and associated with the general disease. It may occur 
as often as secondary symptoms arise. All the other joint inflammations 
are the expression of a focal syphilitic product. The gumma may have its 
seat in the synovial tissue or the cartila^. Fringe formation cannot be traced 
to a chronic hydrops, but must be considered as miliary gummas of the syno- 
viid membrane. The acute hydrops cannot become chronic without formation 
of miliary guinmas of fringes, and even joint inflammation in tertiary and con- 
genital syphilis may be traced to this change in the synovial, parasynovial, 
or cartilagmous tissue. — Abet. Am. Med. 

83. Scarlatinal Arthritis. By £. Palier. Am. Med., July 18, 1903. 

'Hie author states that until recently jouit affections occurring in scarlet 
fever have been considered of rheumatic origin, and anti-rheumatic treat- 
ment has been used. The rheumatic theory is given little credence now. 
Scarlatina now being considered to be of streptococcus origin, the joint affec- 
tions are considered to be of the same origin. Ashby considers joint affeo- 
tioQS to occur in about 2 per cent, of cases of scarlet fever. 

The joint affection is most frequent at the end of the second week aad 



212 ABSTRACT'S 

before desquamation seta in, the severer t3rpe8 occurring where onl^ one 
joint is affected. Littie or no treatment is advised, with the exception of 
soothing ointments and rest. Salicylates often do harm. The author re- 
ports a case, a number of joints being affected. — A. T, Legg, Boston. 

84. Pneumococcus Arthritis in Children. Lancet, Aug. 1, 1003. 

Dunn and Robinson of the East London Hospital report five cases of acute 
joint infection in which the pneumococcus was demonstrated as the cause. 
The age varied from six months to six years. In four cases there seemed 
to be an antecedent cause, pneumonia, bronchitis, otitis media, and measles. 
In two cases the knee only was involved, in two there was a multiple joint 
infection, and in one case tne hip joint was affected. In all of the cases there 
was severe ioint disorganization, although the cases were all operated upon 
earlv and thoroughly drained. 

Three cases di^. Autopsies showed no orimnal focus in the lungs. In 
one case a pure culture of pneumococcus was obtained from the heart. The 
writers conclude that the pneiunococcus plays a much more important part 
in the diseases of children, and e8i>ecially in the joint diseases than is generally 
supposed. — H. W. Jones, St. Louie. 

85. Arthritis accompanjring Qonorrheal Conjunctivitis in the New-bom. 

British Med. Jour., 1885, i. 429; ii. 57, 699, 773. 
We are indebted to R. Clement Lucas for the reco^ition of joint com- 
plications associated with ophthalmia neonatorum. His first report, in 1885, 
WHS greatly criticised, and suggestions were freely made that his case might 
have been one of epiphysitis or syphilitic synovitis. With the exception of a 
case by R. G. Fendick, no parallel case was recorded in Great Britain for 
thirteen years. When in 1899 Lucas again introduced the subject, a search 
through Eluropean medical literature had resulted in the discovery of only 
twenty-three cases. Since 1890 A. E. Garrod, J. Mitchell Bruce, Sydney 
^^tephenson. and L. Vernon-Jones have called attention to the joint affec- 
tions complicating ophthalmia neonatorum, and quite recently C. O. Haw- 
thorne reports a case confirming the results of the earlier observations, more 
especially as regards the possibly quiet nature of the arthritis and the prompt 
and thorough restoration of the efficiency of the affected joints. Unfortu- 
nately there was no bacteriologic examination in this case, although there 
was positive medical testimonv that both father and mother had been in- 
fected with gonorrhoea shortly before the child was bom, and the child began 
to suffer from purulent ophthalmia on the second day. It may be added, how- 
ever^ that in several other instances on record there was undoubted bacteri- 
ologic diagnosis of eonococcus infection in both the conjunctival discharge 
ana the synovial enusion. In this connection Lucas defines two varieties 
of arthritis, namely: (1) a very acute form with features suggesting a tendency 
to suppuration ; and (2) a milder form accompanied by a great deal of effu- 
sion and pain on movement, but with little or no surface redness. Haw- 
thorne's case adapts itself exactly to this latter form. Tlie promptness and 
completeness of the restoration of the joints to normal is in pleasing contrast 
to tne obstinate nature of the ordinary gonorrheal arthritis. The explana- 
tion is doubtless to be foimd in the comparative ease with which the conjunc- 
tival discharge may be checked, and, as noted by Hawthorne, this fact lends 
emphasis to the statement that the cure of the urethral or virginal discharge 
is of first importance in treating cases of gonorrheal arthritis. — Am. Mea., 
Apnl 25, 1903. 

86. A Report of Final Results in Two Cases of Polyarthritis in Children of 

the Type First Described by Still, together with Remarks on Rheuma- 
toid Arthritis. By Royal Whitman. Med. Record, April 18, 1903. 
R. Whitman reports two cases differing in some particulars from those 
described by Still. In one there was complete recovery, of which Still records 



ABS^rilACl>3. 213 

no instance. He mentions enlargement of the spleen only, yet in both these 
the liver was enlareed, in one ending in amyloid degeneration. In Still's 
cases the joints of tne fingers and toes were exempt, wnile the spine was in- 
volved at an early period of the disease. In one of these all the small joints 
were diseased, while in neither was the spine affected. Still mentions slight 
pitting of the cartilage in one case that came to autopsy, while the writes 
examination shows that such erosion is inevitable. The case in which recov- 
ery occurred was treated by daily exposure of the naked body to heat and 
li^t supplied by numerous electric li^ts beneath a tent-like covering. The 
ciure was apparently completed by an attack of scarlet fever. The writer 
classes this disease as an atrophic form of rheimiatoid arthritis, considering 
it as distinct from osteo-arthritis or the hvpertrophic form of arthritis defor- 
mans. It is the common form in early life. The symptoms simulate tuber- 
culosis so closely that diagnosis is impossible until extension to other joints 
shows the true character. The appearances sugeest the effect of a contin- 
uous feeble irritation within the jomt and a feeUe reaction. This indicates 
the removal of depressing influences, proper nourishment, and stimulation 
of local nutrition. Deformity should be prevented and corrected, and there 
should be local support to relieve painful motion. The cause of the disease 
is obscmre. — Abst. Am. Med, 

87. On Hydrops and its Treatment with Medicine. By Sontag. Wien. 

med. Presse, No. 28. 
Argwim, a combination from theobroniiun with acetate of soda, was tried. 
It was well borne, and had in selected cases a most favorable action, espe- 
cially in combination with digitalis or caffeine. — D. Tovm9end, Boston. 

88. Intermittent Hydrops, Healing by Means of Iodoform Glycerine Injec- 

tion. By Wiesinger. Deutsch. med. Woch., Aug. 27, 1903. 
Wiesinger describes a case of intermittent hydrops treated by means of 
the iodoform glycerine injection. He discusses the etiology of the disease 
and its treatment. He advises local treatment in the acute stage, and uses 
iodoform glycerine injection because one may expect thereby a more favor- 
able action on the joint, which will last for a longer perioa on account of 
the gradual absorption of the dru^. He is inclined to consider intermittent 
hydrops as a special though peculiar form of synovitis, but emphasizes the 
need for a more thorough study of the condition. — David Totonsend, Boston. 

89. A Case of Acute, Non-traumatic Multiple Osteomyelitis, Produced by 

the Streptococcus occurring in a Male Adult. By John T. Bottomley, 
M.D., Boston. J&ur. Am. Med. Ass^n, July 25, 1903, xli. 222, No. 4. 
The author describes the case and the operative procedures. He com- 
ments upon it, and reviews the literature of similar cases. This type he 
finds rare. There is a similarity between the staphylococcus and streptococ- 
cus t3rpes. "It seems to be generally agreed that the pus in the streptococ- 
cus cases is thinner and the necrosis of bone and soft parts less than in the 
staphylococcus cases." 

He emphasizes the importance of early and acciirate diagnosis and the 
necessity of opening and draining the medullary cavity. — R. B, Osgood, Boston. 

90. The Chronic Arthritis of Children. By Hans Spitzy . Zeilschr. fur orth. 

Chit., Bd. XI. Heft 4, pp. 699-795. 
The author reviews at length the literature and discusses the published 
cases under the captions: — 

1. Chronic Arthritis following Acute Joint Rheumatism. 

2. Chronic Arthritis following Infectious Diseases. 

3. Primary Chronic Arthritis. 

He discusses the pathological anatomy, the differential diagnosb, progres- 
sion, and treatment in detail, and then reports in full the seventeen care- 



S14 ABSTRACTS. 

hilly studied cases which oonstituie his especial contribution. The referenee 
list contains 94 titles. The pa^ is illustrated bv figures showing cuHuroi 
ai diplococci from the ioint fluid and sections of s3movial membrane from 
one of the cases, also <m bone preparaticms from another case. — G. W. Fitz, 

91. Lipoma Aiborescens. By Charles F. Painter, M.D., and William G. 
Erving, M.D., of Boston. B. M, A S, Jovr,, cxlviii., No. 12. 

The occurrence of fatty growths in the joints is not very uncommon, thou^ 
comparatively few have attracted enoiigh attention to merit publication. 
Tliey have usually been associated with the existence of tuberculosis or ar- 
thritis deformans. They occiur as overgrowths of the synovial villi of the joint 
or as true lipomata that have pushed m from the subserous fat as the result 
of laceration of the fibrous capsule. 

As more cases are being studied, it becomes evident that the etiology is 
not as limited as was at first supposed. Many conditions may cause the 
hypertrophy of fringes. Under some circumstances the result is a general 
villous enlargement, and under others it is confined to one or at most a very 
few villi. The knee joint is the one most commonly affected, though others 
are not exempt. In this series the cases are all operative, and have come 
under observation during the past year. 

The seven cases here to be reported in detail are selected from a series of 
sixteen cases of hypertrophied synovial villi, recently removed at operation, 
because they seemed to represent distinct tumor formations, and not simply 
the wfoorescent over^wthis of the synovial membrane, which are so commonly 
seen. Doubtless this condition of apparent tumor formation is nothing 
more than the end result of the villous hypertrophy, but clinically this condi- 
tion is much the more important to recognize; for the removal of the growth 
not only rids the affected joint of the cause of its symptoms, but removes 
from it a source^ of internal trauma, which would permanently impair the 
function of the joint if aUowed to remain. It is of great importance, then, 
to recognize these growths in the joints, and, in view of the failure to find 
tuberculosis as the cause for the hypertrophy in any of the following cases, 
it seems reasonabl}^ certain that isolated villous hvpertrophies, without 
more symptoms of joint disease, will not be found to oe due to tuberculosis 
infection, and consequently the radical operations, which the literature shows 
have been resorted to in certain cases^ are not indicated because one finds 
villous hypertrophy on opening the joint. The clinical sjrmptoms ^ven 
are those of a foreign body in the joint, and not of disease of the bones or 
soft parts. 

Coplin, in his Manual of Pathology (pp. 242 and 535), savs that he believes 
lipoma arfoorescens to be simply a step farther than "cloudy swelling" in the 

Srocess of fatty degeneration, analogous to the same process in the kidney. 
[e believes it is caiised bv (1) ansemia, (2) necrosis and caseation, (3) bacterial 
toxins, (4) embolism, (5) infections, etc. According to Coplin these degen- 
erations develop in sub^novial or subserous tissues, and push th^ way 
into the neighboring cavities. 

Dalafield and Prudden, in their Patholo^ (pp. 317 and 779), refer to the 
lipoma arfoorescens as pushing into the jomts as "tufts'* of synovial mem- 
brane. 

Hektoen-Riesmann in the American Text Book of Pathology simply ad- 
vance the old theory that these growths are signs of some unoerlying cause, 
as tuberculosis or osteo-arthritis. 

Haeckel reviewed the literature up to 1888, and described two new cases 
of lipoma arfoorescens in his own experience. This article was entitled "Li- 
poma Aifoorescens," and appeared in the CentraJblaU fur Chirurgie, April 
28, 1888. Later still, in the AUg, Chi, fur Path, und Therapie (8 Auflage, 
p. 706), Billroth has another contrifoution to this same sufoject. 

Stieda, in a carefully written paper on lipoma arfoorescens of the knee, 
appearing in the BeUrag fur klin. vkir., xvi. 285, 1896, gives an exhaustive 



ABSTRACTS. 215 

review of the literature on the subject up to that date. Including his own 
two cases, he mentions thirteen, in ten of which the knee was involved, in 
two the shoulder, and in one the hip. 

The first case on record is one described by Goetz in his " Dissert, inaug. 
Halle.," 1798. 

The name "lipoma arborescens" was firat given to the condition by Joh. 
Miiller in his " Ueber den feineren Bau und die Formen der lorankhaften Ge- 
schwulste," while the first suggestions re^^arding its etiology were made by 
Volkmann in the CeniraJblaU fur Chirurgie for 1885. He classified lipoma 
arborescens of the joint, with other clm>nic enlargements, as a condition 
not of necessity primarily tuberculous, but developing into it. 

KAnig, writing in 1885 and again in 1895, consioered the condition as a 
manifestation of tuberculosis only * but, finding later a similar condition in 
cases of arthritis deformans, he at nrst tried to distinguLsh them, and finally 
admitted the great difficulty in so doing. 

Schmolck in 1886 reported two cases, both of long standing, in which at 
the time of operation a fresh tuberculous lesion was found, from which he 
concluded the condition to be one of lipoma of the joint, favoring the 
invasion of the bacillus of tuberculosis. 

(1) Lii)oma arborescens occurs in a number of chronic joint affections. 

(2) It is not a lipoma in the sense of being a ''new growth," but is merely 
a hypertrophy of normal pre-existing tissue. 

(3; Its etiology is a chronic inflammatory condition of the joint, arising 
usually from tuberculosis or arthritis deformans and possibly a condition of 
n^ative pressure in joint. 

(4) Patholo^callv, it is an hyperplasia and fatty degeneration of pre- 
existing synovial tabs, to an extreme degree. 

(5) Histologicallv, the appearance is that of a typical chronic inflamma- 
toiT condition, with, in adaition, a specific appearance in case of tuberculosis. 

(6) In an unopened joint, diagnosis is not certain, the swelling, tender- 
ness, limitation of motion, and ability to palpate not being absolutely diag- 
nostic. 

(7) Prognosis of spontaneous healing and recovery of joint function un- 
favorable. 

(8) Treatment: arthrectomy (erasion), or, when tuberculosis is present, 
resection of the joint. 

With these conclusions the observations would, in the main^ agree. Tuber- 
culosis is given relativelv a less important place in the etiology, and the 
importance is urged of the absence of the clinical evidence of joint disease 
as leading to the diagnosis of a non-tuberculous condition, ana encourages 
exploration of the joint where any doubt exists as to the nature of the patho- 
logical process. 

9X Gelatin by Mouth in Hemophilia. Therapie der Gegenwart, September, 
1902. 
Hesse reports the case of a boy eight years of age, whom he has known 
since birth to be weak, pale, and of slender build. He bruised very easily, 
and his feet often showed blue spots. After each fall he had extensive ecchy- 
moses, especially if he struck his buttocks. His teeth fell out spontaneously 
and he had profuse bleeding from his gums. He bled profusely from slight 
wounds, and often had bloody effusions into his joints. Many things were 
tried, but without result. About a year a^ gelatin treatment was be^n. 
He was nven 200 erams (6} ounces) daily m a 10 per cent, solution mixed 
with raspberries or lemon juice. The improvement was noticeable from the 
first day. For months he has not had epistaxis, gum or joint hemorrhage. 
Blows and knocks produce only slight ecchymoses. His general health is 
much better, [b. l.]— A6«^ Am. Med, 

93. Joint Disease and Hemophilia. Practitioner, 1903, Ixx. 85. 

The occurrence of chronic inflammations as a result of bleeding into joints 
in patients with a hemorrhagic diathesis was first noted by KOnig several 



216 ABSTRACTS. 

yean afCK but still frequently passes unrecogmaed. Though one of the more 
unusual forms of joint affection, it is met with frequent^ enough, so that 
its occurrence should always be kept in mind. This is especially important 
from the fact that operation, which might seem indicated if the condition 
was not xmderstood, is necessarily attended by such disastrous results. Car- 
less, in a paper on surdcal affections of joints, quotes statistics of PoiUet, 
of Lvons, who has analyzed 252 cases collected from literature. This lai^ 
number of cases indicates that the affection is possibly more frequent than 
is generally known. In his original paper, Kdnig describes three stages 
of the affection: First, the joints become distended with blood, usually spon- 
taneously, without any history of injury. There is a feelii^ of tension and 
pain, but no tenderness or symptoms of inflammation. Ecchymosis may 
appear within a few days. Usually the effusion is absorbed in a short time, 
and at first little damage is done. If the hemorrhage is repeated, however, 
— and this is usually the case, — a chronic form of arthritis is produced. The 
synovial membrane becomes thickened and rough, the periarticular struct- 
ures infiltrated, and the articular cartilages and synovial membrane are dis- 
colored with blood pigment, and may be covered with partially organised 
fibrinous tufts, and the muscles are atrophied. In the third stage of the 
affection, loss of function and deformity occur, caused by proliferation of 
periarticular tissue and fibrous outgrowths. The affection appears usuallv 
in early life, frequently between the fourth and sixth years, practically al- 
ways in the male sex. Traumatism does not seem to be an etiologic factor. 
The knee is affected in nearly half the cases, the elbow in about one-fourth 
of the cases, and the ankle next most frequently. The prognosis is always 
bad in hemophilia, it being estimated that 60 per cent, of the patients <ue 
before the age of eight years; but, strange to say, children affected with ai^ 
thritis do not seem to have so great a mortality. It is extremely important 
that the condition be recognized; for a consioerable number of cases have 
been operated upon, with fatal results in nearly every case. Not even punct- 
uro or massage is advisable. The limb should be put at perfect rest, cold 
applications sliould be made and gentle compression applied. Very little 
can be done to arrest the progress of the disease; but, if suitable apparatus 
be applied, much can be done to prevent deformity and relieve pain. — Am. 
Med., March 21, 1903. 

94. Disturbances in Growth and Joint Deformities following Traumatic 

Separation of Epiphyses. Wien, klin. Woch., Dec. 18, 1902. 
Lorenz's first patient fell out of bed when six years old, and compUuned 
of severe pain in right wrist for some time. Now at nineteen it is found 
that the ^wth of the distal portion of the radius has been retarded through 
a separation at the time of its epiphysis. The ulna has continued its growth 
imdisturbed, has torn itself away from the connecting triangular fibro-car- 
tilaee, and produced a deforming prominence at the lower part of the dorsum 
of tlie hand. Resection of the bone was advised in this case. In the second, 
patient of thirty-four, a disturbance in n-owth of the external inferior portion 
of the humerus existed as the result of a separation of the epiphysis of the 
external condyle, when the patient was ten years old. In time the elbow 
enlarged on the outer side, the ulnar nerve became pressed upon, and trophic 
changes were set up in its domain. Excellent photographs and radiographs 
illustrate the deformities. — H, A, WiUon, Am, Med, 

95. Deformities and Disabilities Resulting from Injuries or Disease of the 

Epiphyses. Canadian Jour, of Med & S., November, 1903. 

In this paper by B. E. McKenzie it is pointed out that bones grow in length 
at the junction of the epiphysis with the shaft, and that S3mostosis does not 
occur till adult Ufe. Disease or traumatism may cause synostosis at an 
earlier time and consequent interference with the growth. Where bones 
are parallel, such as in the case of the tibia and fibula, interference with 



ABSTRACTS. 217 

the ^wth of one of the bones may cause a disparity and consequent de- 
formity. 

Injury at the site of the epiphyseal cartilage may cause a part of it to be- 
come osseous while the remaining portion continues to grow. One case 
is reported where this occurred at the jxmction of the lower epiphysis with 
the uiaft of the femur, growing at the inner portion while the outer had be- 
come osseous. Genu varum r^ulted in the affected limb. 

The treatment of these cases has been eminently successful. Seven such 
cases are reported. Where there had been interference with the growth 
of the lower end of the tibia, it was necessary to remove a section from the 
shaft of the fibula to shorten the bone. Then after a linear osteotomy of 
the tibia the deformity was corrected. In a person whose age was such that 
there would be still several vears of growth it was necessary also to chisel 
out the epiphvseal cartilage from the fibula, so that there might not be con- 
tinued growth, causing a recurrence of the deformity. In persons whose 
age is such as to make much increaise improbable in height of the patient 
in the succeeding years, simple osteotomy of the shorter bone will, with 
the removal of the section from the longer bone, prove satisfactory. In 
the case of ^enu varum resulting from partial synostosis of the femoral epi- 
physeal cartilage, the age of the patient being sixteen years, simple osteot- 
onay proved simcient. 

Two cases are reported of acute epiphysitis at the hip joint, causing a con- 
dition resembling somewhat the worst forms of con^i^enital dislocation. Trans- 
position of the portion of the head and neck remaining in one of these cases 
nas secured better anchorage in front of the acetabulum, and osteotomy 
following has succeeded in placing the more deformed limb in a greatly im- 
proved position. 

g6. Diagnosis of Tuberculosis of Bones and Joints. By Ludloff. Trans. 

XXXII. German Surg. Congress. CerUr. fur Chir., 1903, Suppl., p. 5. 

A study of the finer details of the skiagraphic appearances of normal and 

diseased knees of children, which the author expects to be the means of greater 

precision in the diagnosis of focal infections and at an early stage. He nnds : — 

(1) In the antero-posterior view of the knee, from the second to the fifth 
year, the presence normally of protuberances on the internal condyle at the 
epipnyseal line. 

(2) In the lateral view, the presence of an "epiphyseal spot" in the an- 
terior part of the condyle from nrst to fifteenth year, as long as the epiphyseal 
line exists as such. | 

The examination of tuberculous knees has shown certain alterations in 
the appearance of these protuberances and the epiphyseal spots to be char- 
acteristic of tuberculosis. 

Sagittal illumination shows the protuberances to be diminished or absent, 
the condyles enlar^^ as if "blown up," peg-like projections extending down- 
ward toward the tibia. Lateral view shows the epiphyseal spot larger, more 
transparent, and deprived of its normal trabecular structure: its contours 
are sharper. The enlargement is seen to involve not only the condyles, but 
frequently the heads of tibia and fibula and patella, also. 

The reparative process can also be studied bv observing these same details. 

Further study is needed to determine the relation of these facts to etiology 
and treatment. — A, H. Freiberg, CincinnaH, 

97. Sunshine and Fresh Air v. The Ultra Violet and Roentgen Rays in Tu- 
berculosis of Joints and Bones. By Dr. De Forest Willard, Philadelphia. 
Jour, Am. Med. Ass'n, July 18, 1903, xli., 154, No. 3. 
In treating the tuberculous patient, the first object should be to strengthen 
the resisting power of the individual, the second to destroy the bacteria. 

X-rays and Flnsen light affect only a small area. Tuberculosis is a more 
or less general infection affecting the whole body. The importance of food, 
sunlight, and fresh air. Lb therefore great. The results in the author's own 



218 ABSTRACT8. 

practice have been often remarkable. He reviewa the work of Finsen aad 
others, and mentions different kinds of lamps. After discussing the theories 
of action of light rays, he concludes that it is the chemical ray which chiefly 
influences cell action. His own experiments with the finsen light and X-raya 
in combination are described. The following conclusions are reached: — 

(1) Sunlight, fresh air, and good food, together with fixation and pro- 
tection of the affected joint, are the most important agents in the contest 
with tubercular infection. 

(2) All hospitals should have sun rooms. 

(3) Tent life, summer and winter, is practical; and sanatoria for the treat- 
ment of tuberculosis of the hard tissues as well as the soft are needed. 

(4) The absolute value of the actinic and X-rays in the treatment of tuber- 
culosis has not yet been determined, and should be used only to supplement 
operative and mechanical measures. — R, B. Osgood, Boston. 

98. On Varieties of Elbow Joints, Patelle Cubiti and Processus Anguli Ole- 

crani. With illustrations. By KienbOck. Wien, med. Presse, Nos. 

28, 29, 30. 

Varieties of elbow joints, on the whole, seldom occur. In one case was 

found on both sides, interpolated in the triceps tendon, a piece of bone which 

is to be considered as a sesamoid bone, a kind of patella of the elbow joint. 

In two other cases was found an orbicular bony process on the posterior 

border of the tuberosity of the olecranon. — D. Totimsend, Boston, 



CONGENITAL DISLOCATION OF THE HIP. 

99. Present Status of Congenital Dislocation of the Hip and Bloodless 

Reduction. By Virgil P. Gibney, M.D., of New York City. Am. Med., 

May 30, 1903, p. 70. 
Attention is drawn to the impetus given to surgeons in dealing with this 
condition and to the interest developed among the laity by the visit of Lorens. 
After describing the Lorenz method, Gibney emphasizes the necessity <d 
stretching the capsular ligament, but warns as to the danger of paralysis 
of the leg following overstretching. In cases which have passed the age 
limit of seven or eight years, the aim should be to sec\u« a '^ lateral position/' 
as Lorenz terms it (head under the antero-superior spinous process), and en- 
capsulation by the "weight-bearing function." In many cases beyond 
the age limit, after the plaster cast has been removed, he employs hyper- 
extension for a few hours every day bv laying the patient on the face and 
placing a weight of two to ten pounds on the buttocks, and obtains very 
good results from such treatment. Gibney also advocates in patients 
over eight years of age the preliminarv use of traction by weights of five 
poimds, increased in tnree or four weeKs to forty pounds, as rendering the 
reduction much easier. — J. T. Rugh, Philadelphia, Pa. 

100. Morbid Anatomy and Treatment of Congenital Dislocation of the Hip. 
Lancet, Jan. 17, 1903, p. 172. 

Mr. T. H. Openshaw presented to the Clinical Societv of London the sub- 
tect, based upon 70 cases which he had observed, and upon 9 of which he 
had operated. He showed a recent specimen from a girl aged five years 
who had died from bronchial pneumonia. The head of the bone was nor- 
mal in shape with the exception of a small area of flattening at the lower 
end and back part. The neck presented no abnormality. These appearances 
entirely accorded with what Mr. Openshaw had found by operation. In 
his experience, in every case an acetabulum existed; but it was small, shal- 
low, and triangular, and the cartilage forming its floor was thicker than nor- 
mal. In his opinion the head of the femur up to the age of three yean re- 



ABSTRACTS. 219 

mained nozmaL Mr. Openshaw advocated one of two methods of treat- 
ment: (1) reduction of toe shortening by tenotomy and extension and then 
repoflition, so called, of the head of the bone by manipulation as practised 
by Lorenz, or (2) the remaking of an acetabulum by tne open method after 
it had become possible to replace the bone by tenotomy and manipulation. 
As a result of his experience, m about twenty cases treated b}^ the first method 
during the past six years he considered, first, that reposition within the 
joint was an impossibility, and, secondly, that redislocation was exceed- 
mgly common. In the discussion, Mr. J. Jackson Clarke said that he had 
operated upon about twentv cases by the Lorens method, and in only one 
instance had he failed to obtain a good result. In the one case the child 
was su£fering from spastic paraljrsis which had not been recognized, so that 
the failure was explained. Mr. Noble Smith said that he advocated the 
manipulative method, dividing the operation into two stages, by which 
means he believed the amount of force required to effect replacement was 
much reduced. He preferred an apparatus to plaster of Paris for after- 
fixation. — H. A, Wilson^ Am. Med. 

loi. A Discussion on Congenital Dislocation of the Hip. By F. F. Burg- 
hard, London. British Med. Jour., Aug. 29, 1903. 
The article is chiefly a discussion on treatment, though in the beginning 
the author gives a review of the anatomical changes wnich are met, plac- 
ing special emphasis on the variation of the ansle formed by the neck and 
shaft of the femur. He holds that in young chiloren the dislocation is usually 
a supra-cotyloid dislocation, which becomes transformed into a common dorsal 
dislocation as the weight ot the body increases. In speaking of the methods 
for reduction now in vogue, Mr. Burghard takes up nrst the "Hoffa-Lorenz 
operation," giving a precise account of the steps of this procedure. He 
oojects to it as a routme procedure on the grounds that ankylosis seems al- 
most necessarily due to the extensive injury to joint surfaces, and adds that 
the chances for reluxation are much increased, as splints or plaster must 
be removed early in order to institute passive movements to avert anky- 



The author's method is then described. He divides or stretches the ad- 
ductors, and tries the "Lorenz bloodless'' method. If this is successful, well 
and good. If not, after a week he cuts down upon the joint. His incision is 
made from just below the antero-superior spine of the ilium in the interval 
between the sartorius and tensor fascise femoris, the capsule is divided in 
the same line, with the finger the head is guided into the acetabulum. The 
ilio-psoas tendon is divided, as it is regaraed as being a powerful agent in 
reluxation. 

The Lorenz bloodless operation is reviewed, and after a complete state- 
ment of the statistics the following conclusions are reached: — 

1. That all cases should be checked by radiography, and that no 'cure" 
should be spoken of that is not a true anatomical cure. 

2. That all cases of congenital dislocation xmder fourteen years should 
be treated. In the great majority, improvement will result, while in some 
a true anatomical cure is brought about. 

3. That in all these cases Lorenz's manipulations should be tried in the 
first instance. Even should they fail to effect reductions, they facilitate 
any subsequent procedures. 

4. That the prospect of a cure bv the Lorenz "bloodless method" is in 
direct proportion to the age of the child, and that after the age of four there 
is little hope of a true cure by this means. 

5. That in any case the cKances of a true cure by the "bloodless method" 
are not very great. 

6. That an open operation should be done in case the radiograph shows 
the "bloodless method" to have failed to reduce the dislocation, except 
perhaps in the case of a very young child under three years, in whom tne 
manipulations may be repeated. 



220 ABSTRACTS. 

7. That in the open operation no fear need be entertained of shock, bleed- 
ing, or sepeis. 

8. That under no circumstances should the joint surfaces be remodeUed. 

9. That an open operation is more calculated to result in a cure, as it enables 
the sureeon to ascertain beyond doubt when the head of the bone is in the 
acetabiuum. 

10. That the open operation is especially suited to cases over four years 
of age and to those with bilateral dislocation. 

11. That after the operation the limb should be put up in the position 
of maximum stability. In the majority of cases this will De similar to the 
Lorenz position. The limb should be put up in plaster of Paris, immediately, 
and the casing should take in the flewed Knee. This is essential, in order 
to insure stability of the head of the bone. 

12. That all tense structures should be stretched or tenotomised as a pre- 
liminary measure a week or so previous to the open operation. The after- 
treatment is practically identical with that of the Lorenz method. 

In an interesting discussion of the paper, 

Ncble Smith sua that his mind was open as to the value of the relative 
operations. He owes much to Professor Ix)renz, for since seeing him operate 
he has obtained much more satisfactory results than he had M>tainea from 
reading of his method. He reported several reductions, one in a girl seven- 
teen and a half years old. 

R. C. Dun said that he had learned much from watching Lorenz, and had 
operated four cases by this method since his visit with success. 

Robert Jones said that until he saw Lorenz operate he had had no idea of the 
thoroughness of his manipulations. Since his visit he is able to see why so 
many cases have failed to be reduced in England. Out of 38 cases operated 
upon bv the bloodless method since the visit of Lorenz, he has reduced 34. 

A. H. Tubby said that we are never sure in the Lorenz method that the 
capsule is not enfolded by the head of the femur in an' apparent reduction. 
He thinks that the risks to the patient in this form of reduction are fpreaX. 
He prefers an operation by the anterior incision after exsecting a portion of 
the adductor muscles. — N, AUi8on, St. Louis. 

HIP, DISEASES AND INJURIES. 

zoa. A Study of Good Results in Hip Disease. By V. P. Gibney. Med. 
News, Sept. 13, 1903. 
V. P. Gibney calls attention to the fact that many conditions may be mis- 
taken for tuberculous hip-joint disease, such as trauma, periarthritis, coxa 
vara rachitic or traumatic, con^nital dislocation, psoas abscess, poliomyelitis, 
etc. In reference to our aim m treatment he sajs: "Good results are those 
with the minimum of shortening, without deformity, and with the maximum 
range of motion. Results must be studied on a basis of the sta^ in which 
well-recognized methods of treatment are begun. The keen diagnostician 
will recognize the lesion before the deformitsr arises and at an early stage, 
while the poor diagnostician will fcul to recognize hip disease until the mother 
of the child has already made the diagnosis herself. Then the second stage, 
that of deformity, will have been reached and the advantages of early pro- 
tection are lost. The tardy recognition of the value of instruction in ortho- 
pedic surgery by the medical schools throughout the country is largely 
responsible for the destruction of hip loints and the hopelessness of restoring 
functions to points thus impaired. Now we have reason to hope for better 
results because the large and well-equipped schools of medicine have within 
the last decade established such chairs, and the yoimger practitioners who 
will soon make their influence felt will increase the number of those who get 
efficient treatment before the second and third stages are reached. In tne 
third stage we must be content with correcting d^ormity and eradicating 
necrotic areas and sinuses." — Abst. Am. Med. 



ABSTRACTS. 221 

i<Q. A Cheap Tiaction Splint. By L. T. Wikon. B. M. A. 8, Jour., Aug. 27, 
1903. 

The qplint was made primarily fpr a cheap, light splint for bed traction 
and one available to physicians outside of large cities where skilled labor, 
reouired to manufacture the average splints, is not obtainable. 

The upri^t and foot-piece are made from one piece of three-eighths inch 
eas pipe. The upright where it joins the pelvic band b simply heated and 
Battened for about an inch. The lower end forming the foot-piece is heated, 
flattened, and bent to the desired shwe. The pipe should be flattened for 
about four inches upon the upright for tne play of the windlass arm. 

The traction windlass is made of one-eighth steel wire, bent at a right angle, 
one arm being inserted into two holes in the foot-piece, the other Iving along 
the upright, and held by a sliding wire ring. Tne traction windlass holds 
the extension straps in one of three ways, — {I) by a slot cut in the wire, (2) 
by wire pegs inserted into the wire, or (3) by flattening the wire where it 
crosses the foot-piece and fitting a flat piece of steel to this to hold the straps 
in place. 

The pelvic band is cut from sheet steel, and riveted to the flattened end 
of the upright and bent to the desired shape. A firmer hold on the upright 
may be obtained by leaving tabs of steel on the band to be bent around the 
uprif ht. The band may be re-enforced by an extra steel band. Thigh and 
calf hands are made of thin sheet steel. The splint is lengthened by cutting 
the upright in two and inserting a piece of gas pipe of the required length. 
The perineal straps are riveted to the posterior pelvic band. The pelvic band 
may be padded with felt or cotton covered with canton flannel. The 
sphnt costs from 12.50 to $3.50, and weighs about eighteen ounces. — A. T, 
Legg, Boston. 

104. Drainage of Pelvic Abscesses through the Sciatic Foramen. By 
Schmidt. Deutsck. Zeit. fur Chir., Bd. LXIX., Heft 1. 

The recommendation to drain pelvic abscesses of acetabular origin through 
the sciatic foramen was made by Schmidt in Langenbeck*8 Arckiv, Bd. XLVl. 
He believes it has received too little attention. 

Reports having used this method in three cases of pelvic abscess following 
osteomyelitic coxitis. The advantage lies in the natural drainage afforded 
by the backward course of the wound. 

The abscess is first incised anteriorly above Poupart's ligament. Through 
this wound the finger can palpate the internal surface of the acetabular 



iTith the patient lying upon the opposite side, an incision is now made from 
the tip of the great trochanter to the posterior superior spine of the ilium. 
After cutting tnroush the ^uteus maximus, the interval above the pyri- 
formis is sought. Tne supenor gluteal nerve may here have to be sacrificed. 
By means of this ''supra-pjrnform foramen" the finger may now work its 
way into the pelvic aoscess. By drawing the gluteus medius and minimus 
upward^ the capsule of the hip jomt may be explored. This is facilitated by 
prolongmg the incision downward thus simulating the Kocher incision for 
resection. — A. H. Freiberg , Cincinnati, 

105. A Further Contribution concerning Acute OsteomyelitiB in the Region 
of the Hip Joint. By Honsell. Beitraege z, klin. Chir., Bd. XXXIX. 
Hefts. 

A continuation of the study of these cases made by the author with v. 
Bruns and reported in Beitr,, Bd. XXIV. Heft 1. Mention is made of 
articles upon this subject which have since appeared by Beker, Koenig, 
Mangoldt, and Hartmann. 

As material for this paper, 15 additional cases occurring since 1899 are 
used, together with some of the original 106 cases, which have been further 
observed. The questions considered in this paper embrace the inflamma- 



222 ABSTRACTS. 

tory deformities of the upper femoral end, cases pursuing an unusual ooune, 
those presenting diagnostic difficulties, and finally the methods of treatment. 

In lul of the 15 new cases the femur was the primary seat of the disease. 
In the former publication the fact was emphasized that in osteomyelitis oi 
the joint rejgions the foci of inflammation, as a rule, renudn circumscribed 
for a long time or even permanently. Not only in the beginning, but often 
months alter this, circumscribed centres of softening are found in nead, neck, 
and trochanter, not larger than a pea or cherry stone, while diffuse infiltra- 
tion of spongiosa and total necrosis of the femoral segment are unusual. 
When these K>ci become confluent, irregular cavities form which are usually 
recognizable in the skiagram, and whidi sooner or later perforate the bone 
and discharge externally. Located beneath the articular surface of the fem- 
oral head, the cartilage is either lifted or broken through in many places, and 
the head loses its normal shape by caries, and is not infrequently luxated 
from the socket. When the repon of the epiphyseal line is chiefly concerned, 
loosening of the head may occur with faulty reunion, or dislocation of the 
femur, ankylosis of head and acetabulum, necrosis or caries of the head as its 
result. Purulent arthritis always occurs because of the intra-articular posi- 
tion of the epiphyseal line. Large foci may cause bending or fracture of 
the femoral necK. The new cases reported illustrate a numTOr of these con- 
ditions. Skiagraphic tracings are given. 

The cases of osteomyelitic coxa vara are very interesting. Three varie- 
ties are described: — 

1. The whole upper end of the femur is bent, including the trochanter. 

2. Bending at tne insertion of the neck, so that, while the axis of head and 
neck is straight, it makes a right or acute angle with shaft. 

3. The head and neck are bent toward the trochanter minor. The bend 
may be caused either by the size of the foci of softening or by nutritional 
distiurbance from the neighboring suppuration. So, too, the coxa vara may 
result from the faulty reunion of a loosened epiphysis or spontaneous fracture 
of the neck. 

The author takes exception to Schuchardt's statement that the clinical 
course and anatomical changes alwa3r8 stand in a definite relation to each 
other. Cases of foudroyant cnaracter often show lesions of sxirprisingly slight 
extent. However, it may be said that extensive abscesses of sort parts, 
affection of other bones, involvement of viscera, together with the virulence 
of the infective material, are of greater importance from a prognostic point 
of view than the extent of the process in the upper end of tne lemur. It b 
also noted that recurrences and recrudescences of the disease in the hip are 
apt to be frequently malignant in course and termination. The pipgnosis 
ot cases in eany childhood is said to be relatively very good. At this age, 
also, the treatment may be of a more conservative character. Koenig's 
view that the acute suppiurative coxitis of infancy involves almost without 
exception the synovial membrane only is not borne out by HonseU's inves- 
tigations. 

In the diagnosis of difficult cases the X-ray is considered of the greatest 
value. This Lb particularly true of those cases in which separation of the 
epiphysis simulates con^nital luxation. 

With regard to resection in these cases it is held to be unnecessary in many 
of the less severe and in which there is no external evidence of suppura- 
tion. This is also true of many apparently graver cases occurring m the 
first years of life. The skiagram is largelv depended upon to decide the ne- 
cessity of resection in preference to simple incision and also regarding the 
amount of bone which must come away. 

The 15 new cases are reported in fuU. — A, H, Freiberg, CindnnaH, 

io6. The R61e of Atmospheric Pressure in the Hip Joint. By S. W. Allen. 
B. Af . & S. Jour., April 9, 1903. 
Allen reviews the statements as to the atmospheric pressure in the cotyloid 
cavity, and has experimented with cadavers, sueeesshrely cutting the musoles^ 



ABSTRACTS. 228 

capeular lieament and cotyloid ligament. The results of his experiments 
are that ipniat holds the l>one together is primarilv the cotyloid and sec- 
ondarily the capsular ligaments (in life, elasticity of the surrounding struct- 
ures helping them out), and that the air pressure need not be considered. — 
Abst. Jour, Am, Med. Assort, 

107. Acute Epiphysitis causing a Condition subsequently simulating Con- 
genital Hip Misplacement. By John Prentiss Lord, M.D., Omaha. Jour. 
Am. Med. Ass'n, Aug. 1, 1903, xli. 305, No. 5. 

A child at sixteen months had severe lobar pneumonia. An abscess formed 
over the hip durine convalescence. This was opened, and quickly healed 
without definite evidence of articular disease. When seen by Dr. Lord, there 
was no evidence of hip disease. The limb was freely movable in all direc- 
tions save abduction, which was restricted. The deformity was typical 
of congenital misplacement. An unsuccessfid attempt after the Lorens 
method was made to replace the hip. Then a bloody Lorenz-Hoffa opera- 
tion was done, and the head of the bone was found to have been nearly com- 
pletely destroyed. The author quotes the opinion of Dr. W. R. Townsend, 
Dr. Koyal Whitman^ and Dr. Lorenz on the treatment of this condition. 
He points out the difficulty of successful reduction by manipulation when, 
as here, the epiphysitis has almost completely destroyed the head. — R. B. 
Osgood, Boston. 

108. Floating Pseudarthrosis of the Hip resulting from an Osteomyelitis of 
the Joint occurring Early in Life. By Ducroquet and Bezancon. Presae 
Med., No. 15, 1903. 

A child sometimes presents the appearance and gait o^ congenital luxa- 
tion of the hip joint, but palpation snows that there is no trace of a neck 
to the femur and it feels as if it had been decapitated. Radiography con- 
firms this absence of the neck and also of the upper epiphysis of the femur. 
A scar is also found, and the parents relate that in early infancy the child 
had a period of fever and restlessness, terminated by the development of 
an abscess in the hip, which opened spontaneously or had to be incised. As 
soon as it was evacuated, the child appeared to be restored to normal health. 
The rapid recovery excludes the idea of tuberculosis. Li one of the four 
cases described, the mother had an abscess at the time; and in another a vac- 
cination pustule had become secondarily infected. In one of the cases, 
abscesses developed simultaneously in several joints. The prognosis of this 
floating pseudarthrosis is very grave. There is no ankylosis and no tendency 
to the lormation of a socket in the ilium, owing to the absence of the neck 
and otherwise defective development of the head of the femur. One of 
the cases was treated on the mistaken diagnosis of congenital luxation, with 
the inevitable result of total failure of all attempts at reduction. The only 
treatment is the appliance devised for inoperable congenital luxation on the 
principle of Dupuytren's ^rdle. Li taking the cast, a socket for the top of 
the femur must be made m it, and in the appliance, to hold the head of the 
femur down. Another important point is to hold the shoulder and pelvis 
at the proper distance apart. This is accomplished by having the corset 
reach to the axilla, and making it a little higher on this side than on the other. 
Abst. Jour. Am. Med. Aes'n. 

109. The Treatment of Fracture of the Neck of the Femur at Bellevue, St 
Vincent's, and New York Hospiula. By Joseph B. Bissell. Phil. Med. 
Jour., May 30, 1903. 

J. B. Bissell details the results of the treatment of a series of 316 cases of 
fracture of the neck of the femur in the Bellevue, St. Vincent's, and New 
York Hospitals. In none of these cases was an operation performed, dther 
to unite tne fractured surfaces, to remove a detached heaa, or to carry on 
or assist in any manner the treatment. It seems that in all three of the hos- 



224 ABSTRACTS. 

Eitak the patients were kept in bed either longer than was necessary or not 
mg enough. If the broken neck would not unite at the end of six weeks 
under treatment while confined to bed, it is hard to be convinced of the pos- 
sibility of its uniting at the end of eight or nine weeks, especially as "splints" 
do not, in most cases, prevent motion between the fragments and do 
not secure perfect coaptation, neglecting in this way the two essentials — 
immobilization and firm coaptation — ^without which a ''splint" is not 
only useless, but of positive harm. The experience of the writer has led 
him to a much more optimistic view than is usually held; and he would 
surest that the best treatment for this injury would oe an open operation, 
with the pemng or wiring of the fragments, or the application of whatever 
other metn(3^or means may be necessary to retain them in a correct position 
until bony repair takes place. — Abat. Am, Med. 



KNEE. 

no. Bpiphyseolysis with Subcutaneous Periosteotomy in the Treatment of 
Genu Valgum Infantum. By Dr. Max Reiner. Devisch. med WocK,, 
July 2, 1903. 

Reiner reviews his article on "Bloodless Operative Epiphyseolvsis" in the 
treatment of genu valgum of adolescence, which appeared in the Zeitsckr. 
fur orth. Chir., Bd. XI. 

He considers the difficulties of epiphyseolysis in children about eiffht years 
and up, and recommends instead subcutaneous periosteotomy. He describes 
this method, the periosteotome which he uses, and the after-treatment, which 
is the same as that of epiphyseolvsis without periosteotomy. 

In the Vienna Institute for Orthopedic Surgery, cases of genu valgum 
from eight to seventeen years of age are treated by the bloodless epiphyseoonsis 
method; those older than seventeen years of age are treated by ** circumference 
osteotomy"; those younger than eight years of age are treated by the sub- 
cutaneous periosteotomy method. — V. Townsend, Boston, 

III. Traumatic Injuries of Meniscus. By E. Bovin. Upsala Laekare- 
forenings Foerhandlingar, viii., Nos. 3-6. 
Bovin has found in the literature reports of 163 cases of total or partial 
extirpation of the meniscus on account of traumatism. He tabulates the 
detaus of 148 of them: all but 26 were cases of rupture. He further gives 
the complete history of 10 cases he has personally observed and treated. 
He also gives his conclusions in regard to the physiology and anatomy of 
the meniscus from the study of 15 fresh and 36 formaUn-hardened specimens. 
He affirms that the meniscus is not a rigid and un3rielding body, but changes 
its shape and position under the influence of traction and pressure. Twelve 
photogravures accompany this comprehensive article. The median meniscus 
IS found injured much more frequently than the lateral, and isolated rupt- 
ure of the capsular insertion was the most frequent of all. A recent injury 
of the meniscus is often mistaken for an internal sprain or contusion with 
hemarthrosis or for acute traumatic synovitis. An old injury may be mis- 
taken for a free or pedunculated body in the joint or other lesion. The 
slightest suspicion of recent injury of tne meniscus imposes the necessity of 
immobilization and bed rest for three or four weeks after the dislocated carti- 
lage has been replaced. In chronic cases an operation will usually restore 
norm^ function to the joint. An old injury of the meniscus left to itself 
is liable to seriously compromise the function and entail chronic inmo^'itis, 
and possibly arthritis deformans. The meniscus was sutured in 39 cases, 
and m 6 there was recurrence. Infection and ankylosis occurred in 2, ana 
protracted convalescence in 1. The longer manipulations required for suture 
increase the probabilities of infection. Effusion requiring tapping a few times 
followed in 1 case. In 2 others the movements of tne joint were some- 



ABSTRACTS. 23S 

what restricted^ probably from the longer mobilization required after suturing 
than after extirpation. Bovin resorted to suture only once. This was a 
ease of recurrence of the disturbances after partial resection. The fragment 
of the meniscus that had been left was sutured to the capsule with perfectly 
satisfactory results. — Abtt, Jour, Am, Med. Aes'n, 

iia. Fracture thnmgh the Site of an Bxciaion. Canadian M, & S, Jour., 
January, 1903. 
Dr. Gallowav reports an interesting case of a man more than forty years 
of age whose knee had been excised Sept. 18, 1900, because of tubercular 
disease and deformity of the knee. Nine months after the excision, having 
made a misstep when moving backward down some veranda steps, the leg 
was fractured at the site of the excision. The limb was at once placed upon 
a posterior spUnt with some pressure over the seat of the fracture by a thick 
covering of absorbent cotton beneath the bandage. A week later, the effusion 
of blood beneath the skin being considerable, it was withdrawn b^ aspiration. 
The line of fracture could be felt plainlv. There were serrations of bone 
extending upward into the femur and downward into the tibia, showing 
that the yielding had been at points other than exactly the line of union. 
The patient was able to walk upon the limb within two months. He contin- 
ued to wear a back splint for protection for several months afterward. — 
B, E. Mackenzie, Toronto, 

113. Congenital Hyperextenaion of the Knee. By 6douard Delanglade. 
Revue d^Orlhop&tie, May, 1903. 

After studying the pathological anatomy of the cases and indications for 
treatment, the following conclusions have been reached: — 

1. In congenital hyperextenaion of the knee there is a congenital partial 
luxation of tne knee. 

2. There is a forward displacement of the lower epiphysis of the femur, . 
which increases the deformity. 

3. Malposition is maintained by (1) the anterior muscles, (2) the posterior 
muscles which are drawn out of their normal position, (3) by the anterior 
ligamentous contractions. 

Taking advantage of the pliability of the tissues in infants, the best one 
can hope for is: — 

1. Reposition of the tibia maintained until the articular surfaces shall be 
established to meet the normal position. 

2. Endeavor to get right-angled flexion of the knee gradually, so that the 
displacement of the lower femoral epiphysis mav be corrected. 

3. Frequent manipulation and kneading of the soft tissues should precede 
reduction, the hip being flexed, abducted, and rotated outward, so that the 
resisting muscles may oe relaxed as much as possible, relaxing the fascia 
lata and sartorius. — Robert SouUer, Boston, 



SHOULDER. 

114. Myogenous Blevation of the Scapula. By Manasse. Trans. XXXII. 
Germ. Surg. Congress. Cenir, fur Chir., 1903, Suppl., p. 150. 
A case is reported in which the deformity was overcome by cutting the 
levator ang. scap. and the rhomboidei, which were in a state of tonic con- 
traction, and resection of the upper and inner angle of the scapula. After 
seven weeks the deformity recurred, however, because of reunion of the 
levator with the bone. Resection of the levator and rhomboids resulted 
in the permanent correction. However, this operation was followed by 
clonic spasms in both pectorals and serratus anticus, so that the bone made 
jerky movements upwaids, forwards, and outwards. These were not over- 



226 ABSTRACTS. 

come by resection of the pectorals, but galvanic treatment was of much ser- 
vice. — A. H. Freiberg, Cincinnati. 

X15. Congenital Absence of the Clavicles with Photograms and Radiograms : 
Cleido-Cranial Dysostosis. By Harry M. Sherman, M.D., San Fran- 
cisco, Cal. Am. Med., April 11, 1903, 569. 
Sherman reports two cases of this unusual condition which came under 
his own observation, and cites four cases reported by Marie. In the younger 
patients there was present practically no mterference with function, but in 
one of the older ones there was decided impairment. As a causative fac- 
tor, rickets seemed most pronounced, and sti^iiata of degeneration were pres- 
ent in all. Marie believes the condition to be hereditary at times, but that 
it does not run for more than two generations. Nothing is suggested as to 
treatment; but^ should the interference with functions be serious, the thought 
arises that a piece of rib might be used to take the place of the clavicle. — 
J. Torrance Kugh, Philadelphia, Pa. 



FOOT. 

X16. Flat Foot. By Huhner. Am. Jour. Med. Sci,, May, 1903. 

Huhner reports his results of the examination of the feet of 132 white sub- 
jects in his study of weak feet. He finds that 64 per cent, of the males and 
79 per cent, of females had pronation of the feet m some degree. He con- 
cluaed that the reason for the greater proportion in females lies in the vicious 
styles of feminine footwear. 

In 69 male and female negroes examined he found the feet were pronated 
in 85 per cent. He attributes this greater percentage in negroes to their 
laborious occupations. He describes the anatomy of pronated feet, and 
recommends the device of Lovett and Cotton for the milder grades. He 
thinks ridd foot-plates deprive many of these cases of the muscular action 
they neea and induce atrophy. — John L. Porter, Chicago. 

1x7. Flat Foot in Infants and Children. By R. W. Lovett. Jour. Am, 
Med. Ass'n, April 18, 1903. 
The arch of the foot exists from birth. The deformity is generally due to 
heavy children walking early, especially when they are rachitic. It differs 
from flat foot of adults m that there is no tendency to fixation in the abnormal 
position In infants. The cause is the disproportion of the weight and strength 
of the muscles. The usual shoes worn are not suited for those who present 
flat foot. It is a mistake to suppose that moccssins and going barefoot 
will overcome the difficulty. A good boot will improve a flat-footed child's 
standing as soon as it is put on. The muscles should not be cramped, and 
rigid supports avoided. A Thomas sole will often correct the deformity. 
In severe cases metal or celluloid supports may be required, the latter being 
preferable. Some cases may require a shoe with an upright rod attached 
to the leg. Pain is rarely complained of in infants and children, but the 
deformity should be treated and the muscles trained and massaged. — R, Soul- 
ter, Boston, 

118. Considerations on Pathological Treatment of Flat Foot. By Dr. 

L. Heusner, Barmen. Zeitschr. fur orth. Chir,, xi. 2. 
Flat feet are to be grouped under the three heads congenital, rachitic, 
and contracted, the last-named coming under the phvsician's care on ao* 
count of pain. Rigid valgus is carefully described; and a case is referred to 
which resisted ordinary treatment, including forcible correction under ether 
with fixation by plaster. Finally, an apparatus was tried which consisted 
of a strong steel spring with each end fastened into the soles of the shoes in 
such a manner that it held the feet turned in and supinated. Such an ap- 



ABSTRACTS. 227 

paratus acts in the same way as manual correction, and has the advantage 
m acting continuously. 

Then a coUeague of the writer reports his own stubborn case of flat feet, 
and Koes into details as to the various shoes and supports he has tried. 
Finally there is a review of the operative procedures for flat foot. — Henry 
Fei88, Cleveland. 

X19. Weak Foot in Nurses. By J. C. Stewart. Am. Jour, of Surg, d: Oyn. 

The author mentions the prevalence of weak foot in ntirses, especially 
those just starting their training. The first sign of trouble is pain along the 
inner side of the foot or running up the leg to the knee or into the thigh. One 
foot is usually first affected, but the oUier soon follows. Examination at 
first shows no deformity, but on manipulation the tendons of the peronei 
muscles are found tense, and the nurse walks with feet turned out and adopts 
a "clumsy wooden gait." Such cases neglected become confirmed flat feet. 

As a preventive, the author advises that all nurses should wear sensible 
"man-fashion" shoes with wide soles and low heels. 

A case showing signs of weakness should be treated by cold showering, 
massif, and gymnastics. Where painful and showing pronation^ the shoe 
should be built up one-fourth to three-eighths of an inch along the mner side. 

If the foot has reached the spasmodic stage, it should be over-corrected under 
general ansesthesia and put up in plaster, followed in two or three weeks by 
plates. — A. T. Legg, Boston. 

120. A Case of the Disease of Bbret. By C. Pantaleoni. Arch, di Ortop., 
1903, XX. 2. 
A girl of fifteen years entered the Institute Mareh 9, 1900. In January, 
1899, she slipped, and this brought about much distortion of the left foot. 
The ankle became swollen, and the pain was so great that she was obliged 
to remain in bed for some days. Used cold baths and massage. In spite of 
this treatment the foot b^an to turn to the varus position. When she was 
admitted, the position of the foot had become persistent. No disease of the 
nervous system, and the manifestations were entirely local. The treatment 
was bv massage, gymnastics, and electricity. A boot with elastic traction 
was also used. Dismissed April 9, and the continued use of the boot recom- 
mended. There was one relapse, but after some months the cure was main- 
tained. 

laz. On Herpes Progenitalis and Pain in the Pubic Region, Caused by 
Flat Foot. With illustrations. By S. Ehermann. Wien. klin. 
Woch., No. 34. 
The frequent coincidence of herpes progenitalis and flat foot is traced by 

Ehermann to a mechanical tearing of the common pudendic nerve (nervus 

pudendus communis) through the altered static relation of the' thigh and 

pelvis due to the valgus. — D. Townsend, Boston. 



RHEUMATISM AND RHEUMATOID AFFECTIONS. 

laa. On the Condition of the Blood in Rheumatoid Arthritis and Osteoar- 
thritis. By WiUiam G. Erving, M.D., of Boston, Mass. Am. Med., 
Sept. 12, 1903, p. 440. 
Erving reviews the somewhat limited hterature of these diseases, and 
finds that but little investij^ation has been made regarding the hemic con- 
ditions in them. The opinion held by Bannatyne and Forsbrooke, as well 
as by most clinicians, was that anaemia was alwa3rs present, there bein^, 
according to the latter writer, a decrease of 77 per cent, to 52 per cent, m 
the red corpuscles and of 55 per cent, to 25 per cent, in the hemoglobin. Erv- 
ing reports a series of 40 cases, 20 of each condition, in which careful exami- 



228 ABSTRACTS. 

nation was made and the results tabulated. These cases were all in the active 
stages of the disease, and many of them presented the marked anemic ap- 
pearance so frequently observed in these conditions. In both eroups tne 
results were ''a red blood-corpuscle count ranging slightly above the normal, 
while the hemoglobin percentage is close to the 100 mark." ''No abnormal 
dements or signs of hemic degeneration were foimd, and to all appearances 
the formed elements of the blood were practically unaffected in the acute 
stages of the disease." 

Further observation ia hoped for to explain the differences between clini- 
cal observation and microscopic findings. — J. T. Hugh, PhiladeljAia, Pa. 

xa3. The Passing of Chronic Rheumatism. By James J. Walsh, M.D., 
Ph.D., New York. Jour, Am, Med, Aas'n, Aug. 29, 1903, xli. 640, No. 9. 
The author calls attention to the prevalence of the so-called "chronic 
rheumatism" and to the looseness and inaccuracy of the use of the term. 
Among the many conditions which are often diagnosed as chronic rheuma- 
tism he mentions flat foot, relaxed joints, occupation neuroses, gout, the 
various forms of neuritis, and especiallv tne different types of rheumatoid 
arthritis or arthritis deformans. He endEs with a strong plea for a more care- 
ful classification of cases commonly called "chronic rhemnatism," and there- 
fore their more rational treatment. — R, B, Osgood, Boston, 

124. Study of Articular Rheumatism in Relation to Other Joint Affections. 

CeniralblaU f, d, Grenzgebiete der Med, u. Chir., Jena, v. 
In this communication from Moscow forty-six of the latest articles on ar- 
ticular rheumatism are reviewed, including a number of Russian works. 
The writer first points out the incon^^ity of the term "rheumatism" from 
rheuma, a flux, as applied to many jomt affections. Physicians usually con- 
tent themselves with the term "rheumatic" as meaning an affection due to 
getting chilled, but late researches demonstrate that this is very unscientific 
and entails confusion. They should trace the joint affection to its actual 
cause. When this is done, it will be found that a new classification is nec- 
essary. The term "chronic rheumatic polyarthritis" will be reserved for 
the chronic multiple joint affection in which there is known to be an unmia- 
takable connection with acute articular rheumatism. The cases which have 
been hitherto labelled chronic articular rheumatism, but whose oriein is 
obscure, will be classed as chronic polyarthritis without any descnptive 
term. This is certainly better than to ascribe to rheumatism, cases which 
have nothing in common with it except the external appearance. Acute 
articular rheumatism very rarely passes over into the chronic form, and con- 
sequently the number of cases of true chronic rheumatic polyarthritis 
will be found very small. The domain of progressive deforming polyarthritis 
will contain besides the essential polyarthritis deformans and malum senile 
coxae the varieties which have been known as polyarthritis chronica villosa 
hyperplastica, many cases of nodular rheumatism, and some of Heberden's 
nodules (others will be found to belong in the class of uric polyarthritis). 
As the physician learns to trace the connection between the polyarthritis 
and various infections, he will distinguish between the true rheumatic acute 
and chronic polyarthritis and the gonorrheal, the erysipelatous, the typhoid, 
and the pneumococcous. Possibly also the scarlatinal, dysenteric/ tuber- 
culous, S3rphilitic, the neurogenic (in case of tabes and syringomyelia), the 
polyarthritis accompanying osteoarthropathy of Marie-Bamberger, and 
polyarthritis deformans progressiva, urica, and possibly also polyarthritis 
urica, syphilitica^ et deformans. This makes fifteen classes besides that of 
simple polyarthritis chronica. — Ahst, Jour, Am, Med, Ass^n, 

125. Metabolism in Gout. By T. B. Futcher. PraetUioner, August, 1903. 
T. B. Futcher writes with special reference to the relationship between 

the uric-acid and phosphoric-acid elimination in the intervals and during 



ABSTRACT8. 220 

acute attacks of gout. He reports a careful study of three cases and gives 
charts of each, showing a parallelism between the curves of the two acids 
which he believes is a fairly constant one in gout. This intimate association 
of the two acids seems to point toward a common cause and to suggest a 
common source. The author's summary of the studv is: '' The analyses in 
the cases reported suggest very strongly a dose parallel relationship between 
the uric-acia and the phosphoric-acid excretion m ^ut. They further point 
in favor of the view that both are products of nudem disintegration. In the 
quiescent intervals both phosphoric acid and uric acid are markedly reduced 
below normal. Two or three days after the acute arthritic symptoms com- 
mence, the phosphoric acid and uric acid gradually increase until they reach 
the avera^ normal output or even the upper lunit for normal. As the 
acute manifestations subiside, both steadily fall and remain below the lower 
limit for normal until the onset for the next acute attack.'' — Abst, in Am. Med. 

xa6. The Incidence of Qont. By Futcher, Crombie, and Toogood. Practi- 
tioner, July, 1903. 
I. In the United States. — ^T. B. Futcher says that the apparent infre- 
quencv of gout in the United States is due in large part to failure to recog- 
nize the disease. Out of 15,697 medical cases admitted to Dr. Osier's wards 
in the Johns Hopkins Hospital during a period of fourteen years there were 
41 cases of gout, or 0.26 per cent, of the total number of medical patients. 
For the same number of years at St. Bartholomew's Hospital there were 
124 cases out of a total of 33.356 medicfid admissions, or 0.37 per cent, of the 
medical cases. Thus the aamissions of gout to a general hospital are a 
little less than one-third more frequent in London than in Baltunore. All 
of the 41 patients in the series reported were males, and 32 were native-bom 
Americans. Alcohol and lead seemed to be the most potent etiologic fac- 
tors. II. In the Tropics. — ^A. Crombie states that gout is much less frequent 
in Calcutta, and probably in other hot climates, than it is in Europe among 
the same class of patients. The cause of this comparative infrequency is 
believed to be the lower tissue metabolism which is required to raise the 
temperature of the body through a smaller number of degrees. In addi- 
tion to this there is among the natives who adhere to the rules of their relig- 
ion the less nitrogenous nature of their diet. III. Gout as it occurs among 
the Poor. — F. 8. Toogood states emphatically that the consumption of malt 
liquor is the chief, if not the only, cause of the production of gout. Hence 
he doubts that the reallv poor, meaning those in the clutches of downright, 
grinding poverty, ever develop gout. Occupation influences the production 
of the disease to a very slight extent. Work involving special strain upon 
certain joints has no effect in determining the first joint to be attacked. 
Acute attacks of gout in the poor subject are manifested by the same symp- 
toms as in patients of other grades of societv. A characteristic deformity 
of the finders in cases of chronic gout which Toogood has not seen described 
is caused oy the h3rperexteDsion of the joints between the proximal and the 
middle phalanges and the flexion of joints between the middle and distal 
phalanges. Toogood has examined the joints of a number of subjects who 
died from chrome nephritis, and found in a considerable number of them 
crystals of sodium urate, although none had given a history of antecedent 
gout. This point needs further study. — Abet, Am. Med. 

1S7. Osteitis Deformans: R port of a CauBt. By H. J. Sommer. Am. Med., 
Aug. 8, 1903. 
Sommer, after citing the reported cases of osteitis deformans, reports 
a case of typical osteitis deformans, involving practically all groups of bones 
(namely, head, spine, thorax, and extremities), whereas most cases show ex- 
tensive hyperostosis of either (1) the bones of the head, (2) the trunk, (3) 
the extremities, or (4) trunk and extremities. Especially unique in this 
case was the condition of the ribs on the lateral aspect of the thorax where 
the hyperostosis was most marked, obliterating the intercostal spaces and 



230 ABSTRACl^. 

causing the ribs to look and feel, like a large flat bone with comiffations. 
Radiogn^hs oould not be taken, and no post-mortem was allowed. The 
disease lasted eighteen years. The complete measurements of bones are 
given. — A. T, Legg, Boston. 



RICKETS. 

laS. Hitherto Disregarded Sign of Rachitis. By R. Neurath. Wien. klin. 
Woch., Vienna, xl. 1617. 
Photograph of chubby hand in which fin^rs show marked deformity of 
bones. Phalanges appear to be swollen, givmg the fingers a spindle-shaped 
appearance between the joints. He has observed it only in rachitic children, 
and usually in those under a year old. When noted m older children, the 
rachitis is always in a severe form. He was never able to discover the lesion 
in non-rachitic children or in those onl^r slightly affected. It was always 
accompanied by enlargement of the epiphyses and ends of the ribs. He 
found he could diagnose rachitis in cmldren before examining them else- 
where merely bv feefing for the spindle-shaped enlargement of the phalanges. 
It subsided under "phoephorous cod-liver oil," in conjunction with the other 
symptoms of rachitis. — Abat, Jour, Am. Med. Asa'n. 

IS9. Late Rachitis. Zeitsckr. fur kiin. Med., Bd. XLVIII. Heft 1 A 2. 

£. Roos reports a case of a female child who learned to walk properly at 
the end of the &^ year, but had some difficulty in walking, together with 
gastro-intestinal symptoms, in the second year, then fully recovered. In 
her eleventh year she began to show changes in her gait. In the course of 
another year there developed marked bowing of the fore arms and legs, with 
a high oe^ee of epiphyseal enlargement. The cranium and ribs were not 
affected. The case is doubtless one of true rachitis, either developing for 
the first time in the eleventh year or being the recrudescence of a short, doubt- 
ful attack occurring in the second year. Another doubtful case of late rickets 
is also described, and the literature on the subject carefully reviewed by the 
author. There are some differences between rachitis occurring in childhood 
and that developing in the second decade, the most marked being the non- 
participation of the cranial bones. This is accounted for by the slight growth 
which takes place in the bones during the latter period. The results or post- 
mortem and of Roentgen ray investigations show the identity of the two 
conditions. On the surgical side numerous local bone changes have been 
observed in adolescence, such as ^nu valgjum and varum, scolioses, etc., 
which show anatomic and pathologic similarity to tl^ose deformities as they 
occur in childhood. Rachitis has thus proved to be a disease which may 
develop at any time during the period of growth. — H. A. Wilson, Am. Med. 



TORTICOLLIS. 

13a The Pathogenesis of the So-called Menul Torticollis. By V. Bedruschi 
and P. Bossi. Arch, di Ortop., Milano, 1903, xx., fasc. 2. 
A serving-woman of forty-six yeaxs had a brother who was sent to the 
asylum last May for mental alienation. Since that time became low in spirits 
by this preying on her mind, and two months ago torticollis began. The 
neck is now flexed forward and touches the left shoulder, but in dorsal decu- 
bitus is carried to the normal position, where the patient can retain it volun- 
tarily for a few moments. The right shoulder is lower than the left. There 
is marked cervico-dorsal kyphosis with convex lateral deviation to the right 
of the line of the cervical* and dorsal spinous apophysis. There have l>een 
a number of observations of this form of disease. It cannot be cured by sug- 



ABSTRACTS. 231 

gestion, and surreal intervention is irrational. Recent operations by Kocker 
and Ebers show its uselessness. 

1. Mental torticollis cannot be assimilated with tics, and it is distinct 
from spasms. 

2. It ought not be the expression of a psychic disorder, but comes from 
an indefinwle irritative condition from the motor sone of the cortex. 

131. On the Etiology of Spastic Torticollis. By Dr. S. Kofmann, Odessa. 
Arekiv fur Orth., i. 1. 

This is the hundredth case in the literature. The patient, a ^1 of sixteen, 
first noticed slight contractions on the right side of the neck, which grew more 
mariEed, and at the time of the first examination kept up sol day. At times 
they were severe enough to prevent eating and sleeping. The contractions 
began as clonic, and finally became tonic. They ceased at night. The right 
stemo-mastoid had reached to twice its nonnal sise. The patient suffmd 
acutely, and was imable to work. 

She nad tried sea bathing two summers without e£fect. The writer 
tried electricity, massaee, laige doses of bromides, and fixation in plaster 
in the order named, all without avail. Finally, ne operated, excismg 14 
cm. of the spinal accessorv nerve.- Success was marked. At the end of 
seven months the patient nad complete control over the muscles, and was 
practically well except for the deformity of the hypertrophied stemo-mastoid 
muscle, which had m no way lost its strength. According to the statistics 
of similar operations partial or complete success is met with in the great ma- 
jority of cases. — Henry FeisSj Cleveland, 

13a. Surgical Treatment of Localised Spasmodic Affections. La M4deeine 
Modems, April 22, 1903. 
A. Chipault speaks particularly of spasmodic torticollis and contracture 
of the adductors. Cases are cited to prove his conclusions, which are that 
in cases of spasmodic torticollis and spasmodic adductions of the thigh that 
are amenable to surgical treatment all communication between the contracted 
muscles and the central nervous system should be cut off. The cases detailed 
show the superiority of this over other methods, especially those of incom- 
plete nerve resection and of tendon cutting. Complete nerve resection 
merits a consideration that because of diagnostic errors and unjustified 
beliefs of operators has up to the present been refused. — Abst. Am, Med. 



PARALYSIS. 

133. Radial Paralysis Treated by Transplanution. By Allet *ndrini. Arch, 
di Orlop,, 1903, No. 1. 

Extensor paralysis with flexion and pronation contracture in the hand 
of a child following cerebral paralysis, treated by grafting the flex, carpi 
upon the extensor communis through the interosseous ligament. Part of 
it also fastened to the abductor pollicis. Result good after two months. — 
Abet, Cenir, fUr Chir,, 1903, p. 984, A, H, Freiberg, Cincinnati. 

134. Amyotrophic Lateral Sclerosis in a Boy of Fifteen with a History of 
Acute Anterior Poliomyelitis in Infancy. By Alfred Gordon, M.D., of 
Philadelphia. 

The disease which is known under the name of infantile spinal paralysis, 
or acute anterior poliomyelitis, we usually consider as one in which the 
paralysis, the amyotrophy, the secondary deformities, and the arrest of 
development in the affected limbs are confined to a certain portion of the 
bodv, and remain there during the entire period of life. 

When the myelitic focus is replaced by a cicatrix, the patient is left with 
irremediable infirmities, which, nowever, have no influence upon the dur*- 



2S2 ABSTRACTS. 

tion of life, nor upon the integrity of other portions of the cord. This is 
the rule. Nevertneleas, there are exceptions. We are now in possesBion 
of a certain number of facts which prove that the presence of an old myelitic 
focus, though healed up, is not an indifferent factor for the future of the 
patient, so far as his spinal cord is concerned. On general principles a 
locus minoris rtsUteniia can be a point of departure for new inflammatory 
processes, either in the old injured place or in the immediate vicinity or 
at a distance in the same cord. A concussion, circulatory disturbance^ 
infectious diseases, exposure, trauma, are all factors for awakening an ola 
extinguished focus. 

That the acute symptoms of anterior poliomyelitis after a long interval 
of a few or many vears may repeat theniselves in the portions of the body 

greviously affected is well known, but that the acute poliomyelitis may 
e followed by other diseases of the cord is a fact not altogether frequent, 
as the cases on record are comparatively few. Among the spinal diseases 
following spinal infantile palsy, progressive muscular atrophy is the most 
frequent. The perusal of the meagre literature on the subject shows that 
the spinal diseases recorded made their first appearance a great many years 
after the initial symptoms of anterior poliomyelitis, consequently in adult 
or in middle life (Dutil, Ballet, Laneer, J^aehr, Charcot, Hirsh, and others). 

The case reported is of a special interest from this point of view. It 
occurred at a very early age. After a typical onset of infantile palsy at 
the a^e of one year, the disease remained typical until the age of eight, when 
a series of infectious diseases developed. Shortly afterward gradual loss of 
weight and strength was noticed. Still later two fractures occurred in 
one of the affected limbs. The two circumstances gave probably an im- 
petus to the old diseaaed focus, with the result that the same pathologic 
process spread considerably and involved also the pyramidal tract. 

The latter fact makes the case stUl more unusual, because, if progressive 
•muscular atrophy was reported, amyotrophic lateraJ sclerosis was reported 
onl]^ in one case, that of Hirsh. Tne case reported presented ad mlam a 
typical amyotrophic lateral sclerosis. The post-mortem examination showed 
vast degenerations of the white matter between the comua, besides the 
comua themselves. 

Two more points deserve attention. The majority of cases of progres- 
sive muscular atrophy present the well-known Aran-Duchenne's type, in 
which the small muscles of the hands are first affected. That case presents 
the scapulohumeral type of Vulpian and D^jerine. 

The second and last point of importance lies in the fact that the patient 
sustained two fractures of the right humerus, both in the same place, after 
a trivial accident. The occurrence of two fractures in a limb anected with 
an infantile palsy, and the long process of healing (four months), is an in- 
dication that there is a defect of solidity dependent evidently upon a dis* 
turbed state of nutrition of the bony tissue, probably of the same origin 
as the muscular atrophy. As a matter of coincidence (perhaps more), ttie 
patient presents a large th3rroid gland. 

That case is, therefore, one of amyotrophic lateral sclerosb with an atrophy 
of scapulohumeral type developed at a very early age in a patient who pre- 
sents symptoms of an old acute poliomyelitis. 



TENDONS AND MUSCLES. 

135. Tendon Shortening and Lengthening. By Tilanus. NederL Tijdschr. v. 

. Geneeskund, No. 7, 1902. 

Makes a curved skin incision, avoiding the skin overlying the tendon, in 
order to prevent adhesion between skin and tendon wounds and thus insuring 
mobility of the tendon. 

A considerable experience has brought him to the conclusion that in severe 



ABSTRACTS. 233 

cases it is best not to operate more than two tendons at one time, as it is 
easy to go too far. He prefers, should it later seem desirable, to do a second 
op^t^ion. — Abst, ZeiUchr. fur crth, Chir., xi. 3. 

X36. Further Experiences with Silk Tendons. By Lange. Muen. med. Wodi,. 
No. 1, 1902. 

The advantage of the periosteal method of tendon transplantation lies 
in our ability to choose at will the insertion of the new muscle, which will 
at the same time consist of sound tissue only. This requires, however, 
that the suture be made under considerable tension. This is very likely 
to cause necrosis in slender tendons. In place of this Lange interweaves 
strong silk strands into the proximal tendon end, and fastens this bundle 
of threads into the periosteum. In this way a great decree of tension can 
be made without fear. In some instances the artificial tendon has been 
20 cm. long. In two cases out of fifty-six the silk afterward came away. 
As the resmt of function, the new tendons increase in thickness. This has 
been demonstrated automatically in a case where the quadriceps tendon 
had been grafted in this manner two and one-half years before. The new 
tendon was found to have attained a thickness of 2 to 3 nmi.. its lower end 
being continuous with the periosteum of the tibia. The whole tendon pre- 
sented itself as a bluish, round strand, about the thickness of a lead-pencil, 
and surrounded by a layer of loose, mobile connective tissue. The idlk 
threads showed no evidence of d^neration or brittleness. 

Patients were shown in whom the method had been successfuUy employed. 
Ahti. ZeiUchr. fur arih. Chir., xi. 3. 



BANDAGES, PLASTER. 

137. On Removable Bandages and the Combination of Plaster and Celluloid in 
the Bandage Technique. A. Ritschl, Freiburg. Arehiv. fur Orth,, Bd. 
I. Heft 1. 

Ritschl considers the fimdamental principle of the modem treatment 
of fractures of the lower half of the leg to be: to immobilize the part as eariy 
as possible, so as to get a union in the proper position; to diminish the period 
of rest in bed as much as possible by using a stiff bandage; and to allow free- 
dom of the joint as early as possible, to prevent joint stiffness and tissue 
atrophy. He advocates the removable tvpe of bandage in these fractures, 
where absolute rest for a long time would cause injury, because it fixes the 
joint and yet allows movement to the muscles that otherwise quickl^r atrophy. 
It allows some contraction of muscles even when the fracture is not so 
strongly healed so as to bear the weight of the body. For severe eases, unless 
someuimg unforeseen occurs, the bandages can usuallv be removed for the 
first time for exereise at the end of two weeks; in slight cases, earlier. As 
consolidation takes place, the bandage can be taken off daily, and massage 
and electricity sooner or later begun. This shortens the period of treatment, 
and allows the injured limb to keep a considerable portion of its functions, 
which otherwise would be lost. 

He then describes his method of application of the removable plaster 
and celluloid bandages. He advocates tne use of the removable banaage in 
fractures of the ankle and diaphysis of lower extremity, in pseudo-arthrosis 
of lower leg, in reduced luxations of distortions of ankle joint, and in flat 
foot. He hss used it in one case of hysterical club-foot to good advantage. 
He then describes as well his method of procedure in fractures of the 
diaphysis of lower extremity. In general, the removable bandage is indicated 
when It is a question of giving the foot and lower portion of leg the necessary 
support for walking, if at the same time it appears desirable to lay bare tlie 
limb occasionally for the undertaking of treatment that otherwise may bo 
necessary. — D. Townaend, Boston, 



234 ABSTRACTS. 

138. Appumtaa to focUitate the ApplicatUni of Piaster Tackets dnxini^ Spinal 
Hyperextension. By E. D. Fenner, M.D., New Orieans, La. AnnaU 
of Surgery f xxxvii. 92. 
Fenner describes an apparatus devised by Dr. J. D. Bloom, of the New 
Or^ms Charity Hospital, which he considers superior to other similar i4>pU- 
anoes with which he is familiar. It consists essentially of two iron frames, 
padded on the top for the support of the shoulders and pelvis, and a jack- 
screw with rubber ring pad on the top, to be placed directly under the k^rphos. 
All three parts are connected by two iron bars running through slots in the 
bases of each, and are adjustable to fit the patient. Tne patient Ues supine 
upon these three pieces, and corrective pressure is applied by means of the 
screw. When a sufficient amount of correction has been obtained, a plaster 
cast is imphed. The opening in the cast for the top of the jackscrew is filled 
in with plaster after the patient has been removed from the apparatus. He 
claims greater ease of application for the physician, as well sjs greater comfort 
for the patient.—J. T. Hugh, Philadelphia, Pa. 



MISCELLANEOUS. 

139. Some Daily Variations in Height, Weight, and Strength. By T. A. 
Storey. Am. Phya. Ed. Review. 

The author, after numerous observations on the daily variations in height, 
weight, and strength, concludes that there is during the dav a normal 
average loss in height of about 1.452 cm. In individual cases this loss may 
be con8iderabl3r more or less than the average given. The greater part of 
the loss occurs in the region of the spinal column, the average loss here being 
1 .342 cm. There appears to be a loss of 1 .1 mm. below the trunk. The height 
lost during the day is more or less completely regained during the night. 

There is a normal loss in weight each night. The average loss recorded 
was nine-tenths of a pound. The normal daily activities increase the loss 
in weight. The greater the activity, the greater the loss. 

There is a considerable variation each day in ability to make efforts of 
strength. This ability varies from one day to another, and the variation 
amounts to a considerable number of kilograms in the strength tests. — A. 7. 
Legg^ Boston. 

140. New Contribution to the Physiology of Tendon Reflezea. By A. E. 

Stcherbak, Warschau. CenJbral Pyblicatian for Neurology, 1909, No. 5. 

By aid of a large-sized tuning-fork which had been set in motion by electro- 
magnetism the author succeeded in producing spastic phenomena in rabbits. 
The investigations were made on tne knee joint. Here an increase in the 
knee reflex, knee clonus, on percussion and passive movements, and spastic 
vibration corresponding to the '' primary charge" of a different intensity 
and extension, could be demonstrated. In consequence of a vibration of 
the vertebral colunm in the lower dorsal region a series of spsjstic statea 
became noticeable in all the muscle groups of tne hind legs. 

The experiments according to the author seem to make it probable that 
by the aid of vibration we mav be able to change the reflex apparatus, as 
it were^ with nerve energy, and ma^r bring about their discharge oy the aid 
of passive movements or continued immobility of the animal. — Abet. Archiv 
fur Orth., L 2. 

The hueineee manager uill eecure for eubseribers deHring it^ 90 far as praoti- 
cable, and at the lowest possible rates, joumaU or books which contain the original 
of articles abstracted in the Journal. 



Volume I. FEBBTJABY, 1904. Nuxbsk 3. 

"The American Journal of 
Orthopedic Surgery 



I. 

THE RESISTANCE OF TISSUES AS A FACTOR IN THE 
MANUAL REDUCrriON OF CONGENITAL HIP DIS- 
LOCATION. 

E. H. BRADFORD, M.D., BOSTON, 

It is now universally admitted that the chief obstacle in the 
reduction of a congenitally dislocated hip lies in the soft parts 
rather than the bone, and it is manifestly of practical interest 
to determine which tissues offer the greatest resistance. 

It has been a matter of discussion whether the greatest 
difficulty is encountered in overcoming the altered capsule 
or from certain shortened muscles. Reasoning from analogy, 
from normal anatomy, and the strength of the capsule and liga- 
ments of the hip, many writers, myself among them, have be- 
lieved that these rather than the muscles were of the greatest 
importance in maintaining the dislocated position in a con- 
genitally dislocated hip, as the capsule and ligaments ofifer 
the chief obstacle to a dislocation in a normal hip. 

The writer has been led to give up the opinion that in the 
capsular resistance the chief obstacle to reduction is to be 
found, by his recent experience in operating by incision in cer- 
tain resistant cases, from which it has been clear that, even 
after all capsular contraction has been removed and the capsule 
entirely freed from any connection with the neck of the femur, 
the lesser trochanter, or the shaft within half an inch below 

Presented by invitation at the meeting of the American Orthopedic Association, 
Washington, D.C., May 11-14, 1903. 



236 CONGENITAL DISLOCATION OF THE HIP. 

the lesser trochanter, a formidable obstacle often remains to 
elongating the limb to its normal length or to placing the head 
of the femur sufficiently below the acetabulmn. If this ob- 
stacle does not lie in the capsule, it must be found in the mus- 
cles; and, if in the muscles, it appears to be beyond the limit 
of skill by manual manipulative reduction where failure or 
disaster have followed manual reduction. Following this line 
of reasoning, the question presents itself as to the practicabil- 
ity of using a more thorough division of the muscles as an aid 
to reduction than has hitherto been employed. 

Tenotomy and myotomy have been tried in the reduction 
of congenital dislocation of the hip by a few surgeons; but the 
method has not received general acceptance, perhaps because 
the attention of the surgical world has been turned to other 
methods, and perhaps also to a degree because the precise use- 
fuhiess of the method has not been carefully studied. Tenot- 
omy alone will not cure club foot. It is only within a century 
that its general use was advocated. At one time, however, 
tenotomy was regarded as the only important factor in the 
correction of club foot by surgeons, and relapse was the usual 
result. It is certainly true that myotomy and tenotomy of 
the muscles around the hip in congenital dislocation are 
of no benefit unless used in connection with careful manipula- 
tion. Now, however, that the manipulative method has been 
carefully studied and is of approved efficiency, may we not also 
take advantage of tenotomy as an aid? The objections which 
have been urged against the use of the knife in congenital cor- 
rection of deformity are the danger of sepsis, that extensive 
excision would be needed which would lead to cicatrization 
and also that it is an unnecessary procedure. Are these ob- 
jections valid? The subject is one in which anatomical investi- 
gation can be made with advantage. 

Through the courtesy of Professor Dwight the anatomical 
opportimities of the Harvard Medical School were placed at 
my disposal, and an adult dissecting-room cadaver was exam- 
ined by Professor Dwight and myself to discover the possibil- 
ity, with moderate force, of lengthening the limb by traction. 



E. H. BRADFORD. 237 

It was found that where the capsule of the hip joint was freely 
incised a slight amount of lengthening of the limb could be 
gained by traction. When the long adductor and hamstring 
muscles were divided and the fascia lata cut, the limb could 
easily be lengthened two inches more. 

The largest group of the muscles to be considered is the ad- 
ductors. The glutei have been shown by Hoffa and Lorenz 
not to be a factor in the problem of congenital dislocation of 
the hip. The quadriceps extensor, with the exception of the 
reflected head of the rectus, is a femoral muscle; and the re- 
flected head and the psoas iliacus are useful in flexion of the 
thigh, and are of but little importance in the problem to be 
considered. The adductor and hamstring group are mani- 
festly the most important in their resistance to an abducting 
and a traction force. 

If the muscles of the adductor group are examined, it will 
be found that the structure of the several nmscles differs with 
their situation and probably with their function. The adductor 
longus, which is the most prominent superficially, is a long- 
fibred muscle, a companion to the gracilis, and stretched with- 
out the exercise of great force. Its attachment to the sym- 
physis is superficial and easily divided by a knife. This nms- 
cle presents but relatively slight obstacle to forcible correction 
either in abduction or downward traction. The adductor brevis, 
a shorter and thicker muscle, is, as is the medius, attached to 
the upper part of the femur, and serves partly, like the qua- 
dratus lumborum, the pyramidalis and gemelli, to hold the head 
of the femur well into the acetabulum. These muscles are not 
firml}'' fibred and with comparatively few intra-muscular septa. 
They are beyond the reach of the knife in any practical surgical 
procedure short of amputation. Their resistance would be 
to extreme abduction and but little to a downward pull. 

The adductor magnus, the largest and strongest muscle of 
the group, has a double function at its upper attachment to 
the femur. It acts purely as an abductor; and its fanlike 
insertion along the middle of the femur to the junction of the 
middle and lower third makes it, with its fanlike intra-muscular 



238 



CONGENITAL DISLOCATION OF THE HIP 



septa, its toughness, its broad and strong origin, the most power- 
ful of the whole group. The greater part of the muscle is of 
fleshy fibre, but the long inner edges and the lower fibres are 




grouped into a strong tendon, which passes over and to the 
inside of Hunter's canal, and is inserted into the tubercle of 
the femur above the internal condyle. If this tendon is ex- 
amined, it will be seen that it is one of the strongest tendons 
of the body. From its position and strength it is clear that 
it offers the strongest resistance both to downward pull and to 



E. H. BRADFORD. 239 

abducting force. If this is overcome, comparatively little 
resistance will be offered by the other muscles; and, unless this 
is overcome, but little will be gained in resistant cases either 
in elongating the limb or in increasing the arc of its abduction. 
It would appear, therefore, that, if the long tendon of the ad- 
ductor magnus were divided at its insertion at the lower end 
of the femur (a simple and harmless procedure), one impor- 
tant obstacle to diminishing the resistance in correction could 
be removed. After this correction, force in resistant cases 
in the direction of abduction is much easier and resistance to 
a downward pull much diminished. 

The hamstring group presents a formidable resistance to 
a downward pull. The muscles are strong, with long tendi- 
nous insertion. They can be relaxed, however, in manipulative 
correction by flexing the leg, and can be easily divided by tenot- 
omy. The long insertion of the tensor vaginae femoris or the 
ilio-tibial ligament presents a formidable obstacle to down- 
ward traction. If, however, the limb is abducted, the resist- 
ance of the tissue to the success of manipulative correction is 
slight. The ligament is superficial, and can be as easily divided 
by a tenotome as the planta fascia. 

It would appear, therefore, that the chief muscular obstacle 
in manipulative reduction lies in the long tendon of the ad- 
ductor and in the hamstring tendons. It of course does not 
follow that division of these muscles is necessary or advisable 
in all cases, or, if done, will make the manipulative correction 
easy; but it follows that this procedure, not a difficult one, 
will, in the resistant cases, diminish the resistance with no 
increase in the danger. 

The following observations were made at the dissecting- 
room of the Har\^ard Medical School by Dr. L. T. Wilson, and 
illustrate the effect of division of the adductor magnus and 
other tendons on the resistance of a limb to direct traction: — 

A full-term foetus, twenty inches long and weighing nine 
and three-quarters pounds, was placed on its back and its pelvis 
fastened immovably to the table. A traction dynamometer 
was fastened to the right ankle. A pin was driven into the 



240 CONGENITAL DISLOCATION OF THE HIP. 

right interior spine and another hito the right exterior tuber- 
osity of the femur. Slight traction was made to straighten 
the leg and the distance between the pins measured (.4). A 
traction of 30 kilograms was made, and the distance measured, 
showing an increase over A of one-eighth of an inch. The ca{>- 
sule of the hip joint was then divided and traction of 30 kilo- 
grams made, showing an increase over A of one-half an inch. 
Tenotomy of the adductor magnus tendon, with an increase 
over A of one inch. The tensor vaginae femoris was then 
cut, with an increase over A of one and one-eighth inches. 
The hamstrings were cut, with an increase over A of one 
and one-half inches. A traction of 30 kilograms was 
used each time. Traction was then made to see how far the 
femur could be drawn down, and at 40 kilograms the epiphyses 
at the knee gave way. Confirmatory tests on the other leg 
gave similar results. 

An adult male cadaver was taken, and the upper half of the 
body removed at the level of the iliac crests. The pelvis was 
then fastened immovably to the table and to a heavy post. 
A dynamometer was fastened around the right ankle, and u 
tackle fastened to this and to a heavy post. A nail was driven 
into the anterior superior spine and another into the external 
tuberosity of the femur. Traction of 175 kilograms was made, 
and the distance between the nails measured (^4). The cap- 
sule was then cut (see later remarks) and traction of 175 kilo- 
grams made, showing an increase over A of one-half an inch. 
The tendon of the adductor magnus was tenotomized and trac- 
tion made, with an increase over A of three-quarters of an 
inch. The hamstrings were cut and tension made, with an 
increase over A of three-quarters of an inch. The fascia lata 
was then cut and tension made, with an increase over A of 
seven-eighths of an inch. 

These results being far from what was expected from Ex- 
periment I., investigation was made and the capsule found 
not to be divided in many places, especially the back. This 
was fully cut and tension of 175 kilograms made, and an increase 
over A found to be one and one-half inches. 



E. H. BRADFORD. 241 

A second hip was treated in the same manner with the fol- 
lowing results: A traction of 150 kilograms was used. Meas- 
urement of A taken. Increase over A with the capsule thor- 
oughly divided, one-half an inch. Increase over A with the 
capsule thoroughly divided and a tenotomy of the adductor 
magnus, three-quarters of an inch. Increase over A with the 
capsule cut and a tenotomy of the adductor magnus and tenot- 
omy of the hamstring, three-quarters of an inch. Increase 
over A w^ith the capsule divided and tenotomy of the adductor 
magnus, hamstrings, and fascia lata, three-quarters of an inch. 
This case, however, was an old dissecting-room subject which 
had had the skin removed, and the muscles were fairly hard 
and dry. 

Nothing could be more simple than the method of Lorenz 
in correcting the deformity in a young child, but in the more 
resistant cases the amount of force necessary brings the operator 
face to face with the danger either of using too great force, 
and causing an unnecessary injury, or too little force, and fail- 
ing to effect reduction. Fractures of the femur may occur 
with injury to the soft tissues, due in part to the difficulty of 
regulating the amount of force used. There is difficulty on 
the part of the operator in securing the pelvis under his con- 
trol, as both of his hands are occupied in the manipulation of 
the leg: the pelvis is left to an assistant. It is impossible that 
there should be complete harmony of muscular effort, and either 
too great or too little force may be used, too great fracturing 
or bruising tissues unduly or too little not overcoming the chief 
resistance, which appears to be the lower tendinous insertion 
of the adductor magnus. To stretch this muscle efficiently, 
it is necessary that the pelvis be held securely, that there be 
traction force combined with an abducting force. If this force 
is arranged in such a way that the trochanter is pressed upon 
an immovable fulcrum and the limb is sufficiently pulled at the 
same time it is abducted, there must be slight danger of fracture 
of the femur by crowding the head into the pelvis or resistant 
tissue. The resistance of the adductor magnus may be assumed 
to be less than the strength of the shaft of the bone. The ad- 



242 



CONGENITAL DISLOCATION OF THE HIP. 



ductor magnus protects from motion injmioiis to the soft tis- 
sues, and these vessels and nerves cannot be injured until this 
tendon is stretched, torn, or divided. 

It is essential that the mechanical force employed should 
be directly under the control of the operator. 




4 f¥'emtfi i*'ff'-f 



The necessary requirements are met with success in an ap- 
paratus devised by Mr. Bartlett, of Boston, after careful in- 
vestigation of the subject and observation of cases and patho- 
logical specimens at the Children's Hospital and Harvard Med- 
ical School. A full description of the device will be published 



E. H. BRADFORD. 243 

later, but a less detailed account may be of interest. It con- 
sists of two metal cylindrical posts adjustable on a stand to 
press upon the pelvis above the trochanters. On these metal 
cylinders metal collars fit, to which a strong steel rod is secured 
with a windlass traction attachment. A rawhide strip hitched 
with a clove hitch to the padded ankle of the patient provides 
for traction to any desired extent, counter-pressure being fur- 
nished by a metal perineal post. The traction rods are secured 
to the metal collar, which plays about the cylindrical post. 
Abduction and adduction, flexion and hyperextension combined 
with a pull, are provided for. The cylindrical post acts as a 
fulcrum to the abducting force of the rod; but, as the centre 
of this motion is outside of the position of the femoral head, 
abduction alone will act as a force which will bring the head 
of the femur from above the acetabulum to its level, if sufficient 
additional force is applied to stretch the hamstrings and ad- 
ductors. To secure direct pressure upon the capsule and any 
contracted fibres which prevent the descent of the femoral 
head, a superimposed cylinder is placed upon the trochanter 
cylinder; and on this a metal collar is fitted with a handle on 
one side and an arm on the other, fitted so as to press above 
the trochanter above and below the femoral neck. If this arm, 
while the limb is being stretched and abducted and the head 
pulled away from the ilium, can be forced down, the femoral 
neck and head will be pressed before it, provided the arm is 
fitted snugly around the neck and slipping is prevented. This 
is prevented by a cam motion of the superimposed cylinder, 
which is worked by a wrench. The surgeon holds the handle 
which directs the pressure on the trochanter, and at the same 
time moves the wrench, forcing the cylinder to revolve, exert- 
ing a downward pressure of any required force and with adjust- 
able accuracy. Under this force there is no danger of a fract- 
ure of the femoral neck or head, as they are free from resisting 
pressure. The tissues which will be torn are the shortest tis- 
sues alone, which can be torn without danger. 

The objection to this appliance is the objection of every 
surgeon to all mechanical aids. Few surgeons have mechan- 



244 CONGENITAL DISUX^ATION OF THE HIP. 

ical ability or training; and they prefer their unaided hands, 
amied, if necessarj', with a scalpel. This objection, however, 
is not of great value. The reduction of resistant dislocation 
of the hip is the work of a specialist, and the specialist should 
train himself in the most effective methods. 

In order to test the efficiency of the Bartlett machine, experi- 
ments were made on an adult cadaver; for, if the resistance 
of the tissues and capsule could be so far overcome as to pro- 
duce a downward dislocation of the hip in an adult cadaver, 
it is to be presumed that its efficiency could be relied upon in 
the congenital dislocation of a hip of a child. The following 
is the result of an experiment conducted by Dr. Wilson, Mr. 
Bartlett, and myself at the Harvard Medical School : — 

An adult male cadaver was placed in the apparatus. The 
ankle of the right limb was secured to the traction rod, and a 
dynamometer was attached to register the amount of force 
employed. When a traction force of 160 kilograms was ap- 
plied, the limb was abducted to an angle of 50° with the long 
axis of the body, and the dynamometer registered a pull upon 
the fenmr of 220 kilograms. No dislocation of the femoral 
head was developed. The cylindrical post was then turned 
by means of a wrench on its eccentric and the downward press- 
ure upon the neck of the femur exerted, with the result of a 
dislocation of the head of the femur one inch below the acetabu- 
lum. The experiment was repeated upon the other femur 
of the cadaver with a similar result. The amount of force re- 
quired was not carefully registered by the dynamometer, as in 
applymg the force to the upper eccentric the amount of abduc- 
tion of the limb was lessened, thereby lowering the traction 
force, and the force registered upon the djiiamometer remaineil 
as before 220 kilograms. 

From this it would appear that no mechanical obstacle exists 
to forcing the femoral head downward from its fixed position 
by the use of force within surgical limits. Experience with 
osteoclasis has demonstrated that a pressure of much over 250 
kilograms is borne by tissues without injury. A traction force 
and an abducting force combined with a downward force upon 



E. H. BRADFORD. 245 

the head of the strongly abducted femur appears to present 
an economy of effort. 

As a complement to these experimental investigations, the 
principles here presented have been utilized practically at the 
Boston Children's Hospital in cases of congenital dislocation 
of the hip under treatment for the last four months. \ 

The method of manipulative reduction with the aid of tenot- 
omy of the adductor magnus tendon has been performed at 
the Children's Hospital in three cases. These cases were not 
of the most resistant type, but the aid given to the manipula- 
tion, making the correction much easier, was apparent. 

Correction by the aid of mechanical force by the Bartlett 
machine without tenotomy has been done in a child of nine 
and in a child of six, fairly resistant cases, with success and 
much less effort than would be necessary by manual force. 
A combination of mechanical force and tenotomy was employed 
with great success in a child of thirteen, the reduction being 
made with great ease. This method has been tried in two 
younger children with success; but, as the Lorenz method is 
simple and efficient in the younger cases, mechanical force is 
imnecessary. 

The facts which are here presented for consideration may 
be summarized as follows: — 

(1) The resistance offered by the capsule to the correction of 
congenitally dislocated hips is not more important than that 
offered by the muscles. 

(2) The chief resistance to forcible adduction is from the 
strong tendon of the adductor magnus. 

(3) The resistance to pulling down the head comes from the 
hamstring group and the long tendon of the adductor magnus 
and ilio-tibial band. 

(4) These resistant tissues can be overcome by small incisions 
at a distance from the hip. 

(5) In the lighter cases manual manipulative reduction is 
sufficient. 

(6) In resistant cases mechanical force which pulls upon 
and abducts the limb, arranged so as to also directly act upon 
the capsule, is of assistance. 



246 CONGENITAL DISLOCATION OF THE HIP. 

(7) Where the tendon of the adductor magnus is so strong 
that an immoderate amount of force is needed in stretching^ 
it would seem advisable to divide the chief resisting tissues 
rather than to incur the danger of severely bruising the tissues 
by the force used. The division of the tendon can be done 
either before the operation of forcible correction or at the same 
time. 



II. 

CONGENITAL DISLOCATION OF THE HIP: REPORT 
OF A BLOODLESS REPOSITION, FOLLOWED BY 
DEATH, WITH AN ANALYSIS OF TWENTY-THREE 
CASES IN PROCESS OF TREATMENT. 

H. AUGUSTUS WILSON, A.M., M.D., OF PHILADELPHIA, AND J. 
TORRANCE RUGH, A.B., M.D., OF PHILADELPHIA, WITH PATH- 
OLOGIC REPORT BY W. M. L. COPLIN, M.D. 

The clinics held by Professor Adolf Lorenz on Dec. 11 and 12, 
1902, at the Jefferson Medical College Hospital and the wide- 
spread accounts of his methods and skill naturally attracted many 
people to his bloodless methods of reduction of congenital dis- 
location of the hip. Many patients were brought for treatment 
by the non-cutting method that were beyond the age limit 
set by Lorenz, and often positively refused to have even subcu- 
taneous tenotomy performed. This will explain the fact that 
patients beyond the age of seven were operated upon by the 
bloodless method that were considered too old for that method, 
and yet at least three cases were found to present conditions 
that rendered the reduction much easier than in some of the 
younger children. 

All of the patients that have been operated upon at the Jef- 
ferson Hospital during and since the Lorenz clinics are in proc- 
ess of treatment, as six months from the time of operation 
have not yet elapsed. It is proper to speak of them at this 
time only as to the reduction; and later, when their plaster 
casts are removed, the results can be determined. 

The members of the orthopedic department who assisted 
Dr. Lorenz on December 11 and 12 were H. Augustus Wilson, 
J. Torrance Rugh, F. E. Dolson, T. D. Taggart, with G. J. 
Schwartz, etherizer, supplemented by Dr. Frederick Miiller 
and D. D. Ashley. The twenty-three hips operated upon in- 
Presented at the Seventeenth Annual Meeting of the Association, Washington, 
O.C, May 11-14, 1903. 



248 



CONGENITAL DISLOCATION OF THE HEP. 



elude eight done by Lorenz and the above-named assistants, 
thirteen done conjointly by the staff of the orthopedic depart- 
ment, and two done outside of the hospital by Dr. Rugh. The 
details as practised by Lorenz have been most critically carried 
out. It was deemed unwise to attempt the least departure 
from the methods which Lorenz with his vast experience and 



GowNo. 


Nnme, 


8«x. 


land 2 
8 


RE?C. 


Girl 


4 


A. P. 


6 and 6 


M.I. 




7 and 8 


M.G. 


*• 


9 


G.R. 


11 


10 and 11 


H.L. 


t« 


12 


K.C. 


«i 


14 and IS 




B?7 


16 


M. H. 


Oirl 


17 


R. M. 




18 and 19 


B. D. 


ti 


20 


E R 


Boy 


21 


R.M. 


Girl 


22 


K. McF. 


•• 


23 


J. 8. 


Boy 



Aira. 



21 months 
20 •* 

9 years 

4 - 

4 *• 

7 " 

2 " 

7 ** 
4 *• 

10 " 

8 " 
7 " 
7 " 
9H " 

3 - 



18 months 



Dftte. 



Dec. 11 



Dec. 12 

Mar. 3 
Feb. 6 
Jan. 7 
Mar. 2 

Feb. 11 
Mar. 21 
Mar. 3 
Mar. 18 
Apr. 16 
Apr. 20 

Feb. 1 
Mar. 8 



Doable 
Left 

Doable 



Left 
Doable 

Riffht 
Doable 
Ri«rht 

Left 
Doable 

Left 



Operator. 



I Lorenz, assisted by 
Miiller. Ashler, 

Y Wilson. Ruffh. 
Dolson, and Tas- 

I ffart. 



Wilson, assisted 
by Ruffh, Dol- 
son, and Taff- 



son, 
gart. 



JRagh. 



is doable (l doable 

(Sleft. 6boys{ (3left. 

7 single { (4 single \ 

bright. (iright. 

16 doable 
(Sleft. 
11 single { 

(3 right. 

6 oases 2 years and onder. 

2 cases 2to3 years of age. 

6 oases 3 to 4 years of age. 

6 cases 6 to 7>year8 of age. 

3 oases 8 to 9 years of age. 

2 cases 10 years of age. 

23 

consummate skill had demonstrated before a most critical au- 
dience of 700 medical men. That we lacked his ability was of 
course to be expected, but each of us became more and more 
convinced with each case, that in suitable cases great force was 
unnecessary when skilful manipulations were employed. The 
very great force that is sometimes spoken of in connection 
with this method is employed only in those older patients in 
whom use has developed strong and resistant muscles and 
fibrous materials in relations with the hip or when imsuccessful 



H. A. WILSON AND J. T. RUGH. 249 

attempts have been made at reduction. Professor Lorenz found 
the reduction to be accomplished with ease in the first four 
hips, notwithstanding that one of the patients was nine yeans of 
age. The next one, aged four, proved to be extremely diffi- 
cult, and taxed Dr. Lorenz's skill and strength almost to the 
limit, but finally yielded and demonstrated a satisfactory 
reduction. 

The last patient, aged four, with double dislocation, had been 
placed under ether to be in readiness, but could not be operated 
upon because of the difficulties encoimtered in the former case. 
The child had been imder ether for thirty-five minutes before 
it was decided to postpone reduction in her case. She made 
a satisfactory return to consciousness. Thp day following 
she was again etherized, and Dr. Lorenz reduced both hips. 
She went to the ward in good condition at 6 p.m. 

The following notes are given by Dr. P. H. Moore, the house 
surgeon. The phenomena were also witnessed by Dr. Wilson: — 

At 9.15 P.M. the right hand was observed to begin to move in an indefi- 
nite, convulsive manner, and the patient rapidly passed into a state of stupor. 
The eyes became fixed, pupils dilated, and did not respond to light, the tongue 
protruded, and frothlike saliva dribbled from the mouth. The face was 
markedly pallid and cold. Breathing was somewhat slower than normal 
and labored. Occasionally the lower jaw moved slightly, but there was no 
biting of the tongue. The pulse was not rapid, but decidedly weak. Later 
it became rapid, and could not be counted, owing to arm movements. The 
right leg was several degrees lower in temperature than the left, and offered 
almost no resistance to manipulation. In three-quarters of an hour the stupor 
began to lessen, respiration became more nearly normal. A slight flush came 
to the cheeks, the tongue retracted, and the muscles of the face showed some 
twitching movements. The right hand underwent convulsive movements, 
the head was turned violently from side to side. There were mild clonic 
convulsions of the muscles of the back, and speech, slowly restored, became 
coherent. In about one and three-quarters hours the condition was practi- 
cally the same as before the attack. The child did not sleep. At 12.30 
(same night) there was a much briefer attack, showing some of the above 
phenomena in modified form. Restless sleep until morning. There was no 
recurrence, and no resulting paralysis. The child was languid. 

Professor Lorenz, in a personal commmiication, said (after 
reading the above record of the phenomena) that he had never 
had a case in which convulsions followed the operation, and 
he considered shock and tramna as the cause of this case. 



250 CONGENITAL DISLOCATION OF THE HEP. 

K. C. — ^The radiograph was relied upon, and it showed the 
condition of the acetabulum and the head of the femur to be 
favorable. There had been a cutting operation performed 
two years previously, and it was stated that this was for the 
evacuation of an abscess. The head of the bone seemed to be 
easily pulled down to N^laton's line before the reduction was 
attempted. It was discovered later, during the manipulations, 
that there was no head to the femur; and we inferred that it 
had been removed at the operation referred to. It was found 
to be impossible to obtain any information as to what was really 
done, although careful inquiries were instituted. The hos- 
pital where the child was operated upon was under a staff that 
was not in affiliation with members of the American Medical 
Association. 

M. H. — Some considerable cedema of the right labium majus 
developed about ten hours after reduction of the hip, which 
necessitated catheterization for twenty-four hours; but it then 
subsided, and normal functions were re-established. 

With these few exceptions the patients all progressed favor- 
ably, and, after remaining quietly in bed for from three to four 
dajrs, were permitted to sit up, and were usually sent out of 
the hospital witliin a week from the time of operation. They 
were kept under observation by physicians in attendance upon 
the families, and [reports were made to the Jefferson Hospital 
from time to time. 

In not one case has there been any evidence of paralysis or 
other nerve disturbance. Pain on attempting to use the leg 
operated upon has generally persisted for two to four days, 
and after that was only present when the hamstring tendons 
were stretched in those cases in which some flexion of the knee 
persisted. This, however, soon subsided, and freedom from 
pain or annoyances of any kind has been the condition in all 
cases, excepting only the inconvenience of the plaster cast and 
the position in which it held the leg. It was a matter of great 
iaterest to see how quickly the children learned to adapt them- 
selves to the posture of the affected leg, and to use it in walk- 
ing where only one hip had been replaced. 

We were surprised to see how little attention Lorenz paid 
to the very carefully prepared skiagrams that accompanied 



H. A. WILSON AND J. T. RUGH. 261 

each of the twenty cases submitted to his inspection and se- 
lection for his clinics on December 11 and 12. His reliance 
on clinical inspection of the case, the thorough manner in which 
he determined the existing conditions and the prospects for 
reduction, impressed every one with his rapidity and certainty 
of action and decision. 

Subsequent experience has convinced us that the well-recog- 
nized possibility of variously interpreting radiograms renders 
their use of much less real value than would naturally be suj)- 
posed. 

It cannot be disputed that aid can be obtained from a care- 
ful study of a radiogram in direct connection with the analysis 
of the clinical phenomena, but the latter are to be relied upon 
for definite facts as to the condition of those factors about the 
joint other than bone which play equally important parts in 
resistance to reduction. In the caae of M. I., that Professor 
Lorenz found the most difficult of all to reduce, the radiograph 
showed a most favorable condition, and was therefore most 
misleading. The same thing has been found in several other 
cases, notably in E. K., age ten years; and the radiograph indi- 
cated imfavorable conditions for the bloodless method, which 
was attempted only as a preliminary measure in order to prepare 
him for a cutting operation to be performed later in accordance 
with the teaching of Lorenz. Reduction, however, was accom- 
plished by us with far greater ease and certainty than in many 
of the other cases. The only fatal result is here fully recorded : — 

On March 10, 1903, B. D., a girl, aged seven and one-half, was first seen 
by Dr. Rugh, she having been sent by the family physician. Dr. I. A. Fries. 
Tlie family history showed tuberculosis on the father's side, a brother having 
died of pulmonary tuberculosis, but no history of any similar deformities 
on either side of the family. 

The patient was the oldest of three children: the second one, however, 
died in its fourth year from meningitis. Birth of the patient was normal. 
She had measles at three years of age. All three of the children had very 
large heads when bom ; and the disproportion remained quite marked, giving 
the appearance of hydrocephalus. Patient never was a robust child nor a 
hearty eater, but seldom complained of illness. When nearing two years 
of age, she began to walk; and the family physician began to notice that she 
appeared much shorter when standing than when lying. A careful exami- 
nation revealed to him a double congenital misplacement of both hips up- 



262 CXDNGENITAL DISLOCATION OF THE HIP. 

ward and backward on the dorsum ilii. He immediately sent her to the 
orthopedic department of a hospital in this city, where she remained under 
treatment for nearly two years. The treatment consisted in extension for 
over a year and then the application of plaster of Paris with the legs in the 
position of slight flexion and slight abduction. Radiographs taken at the 
time showed the heads of the femurs to be opposite to, but not in the acetab- 
ula. Braces were later applied and worn for two years, but the hips remained 
misplaced and her gait was very much impaired. When she was examined 
on March 10 and later, she presented the following appearance: A rather 
delicate-looking child of ordinary height and somewhat under weight. The 
calvarium was very broad, the face somewhat narrow, accentuating the rachi- 
tic tendency, and the veins of the forehead and neck were quite prominent. 
The skin was almost transparent, and presented a very waxy appearance. 
The chest was spare, but of normal size, the abdomen retracted, the ex- 
tremities thin, and the muscles weak. There was marked lordosis of the 
lumbar spine, and the gait was very awkward and rolling. The knees pre- 
sented a pronoimced condition of genu recur\'^atum and knocked together 
in walking. The ligaments of the several joints of the lower extremities 
were very much relaxed, allowing considerable abnormal motion. The feet 
were in the position of valgus, and the toes were markedly everted. The 
hips were very freely movable, and on standing the femoral heads and tro- 
chanters stood out prominently. They could be drawn down to the acetabula, 
but not opposite. Muscular control was good, but the muscles were weak. 
The adductors were very much shortened, as were also the flexors; and the 
thighs could not be abducted in the line of right-angled flexion beyond 45**. 
The radiograph showed fairly well-developed femoral heads and acetabula. 
There being no apparent counter-indication present, bloodless reposition was 
advised and assented to by the parents after the dangers were outlined to 
them. The patient entered the Jefferson Hospital on March 17, and was 
prepared for operation in the manner usual at that institution; namely, 
regulation of the diet, bowels and secretions, with rest in bed for a period 
of not less than twenty-four hours. The examination of the heart and lungs 
was negative, and the urine examination was as follows: urine clear, straw- 
color, acid reaction, faint trace of albumen, 1.5 per cent, urea, amorphous 
urates, squamous epithelial cells, and a few leukocytes. The operations 
were performed the following day at eleven o'clock by the writers, assisted 
by Drs. Dolson and Taggart, and the anesthetic was administered by Dr. 
G. J. Schwartz, the official anssthetizer for the orthopedic department. The 
right hip was first attempted, the various steps of stretching and tearing 
the adductors and flexors being carefully followed out, and then external 
rotation and circumduction with hyperextension in the abducted position 
was employed, but reduction failed. A very significant thing occurred 
. while tearing the adductors, but was considered at the time as not having 
any special significance. As soon as abduction was made in the tearing of 
the adductors, the skin over these prominent muscles where massage was used 
began to tear, showing the low state of vitality present. This occurred on 
both sides; and, wherever pressure was made by the hands, for means of re- 
duction, a blue mark appeared. 



H. A, WILSON AND J. T. RUGH. 263 

After several more attempts in the same mamier were made, the yam 
rope was attached to the ankle and traction made to stretch the capsule 
downward, as well as to bring the head opposite the acetabulum. The hip 
was manipulated while this was being done; and then reduction was again 
attempted, but was not accomplished. While the hamstrings were being 
stretched, something was heard to snap, and it was thought to be the tendons 
of the semitendinosis or semimembranosus muscles; but this was evidently 
when the ischium was fractured, although it did not seem like a bone break- 
ing. When traction was being made on the femur, a tearing sound was 
noted, and was supposed to be the Y-ligament; but evidently the femoral 
neck was fractiued instead, although it could not be recognized at the time. 
After twenty-five minutes' work by both operators, the head was thought 
to be placed upon the acetabulum, as the leg could not be straightened at the 
knee; and this was given by Lorenz as the sign of replacement. 

The child's condition seemed good, and it was decided to attempt the re- 
duction of the left hip at once. No greater difficulties to reduction appeared 
in the left leg than were encountered in the similar stages with the right, but 
the skin likewise gave way over the adductor tendons. The strong resistance 
of the hamstring tendons induced the operators to cease further efiForts after 
fifteen minutes' time, when it was realized that reduction by the bloodless 
method was impossible without unduly prolonging the manipulations that 
were made. It was decided to place the legs in the best possible position 
for repair of the torn structures, and subsequently to resort to the intermedi- 
ary operation of cutting down upon the joint and stretching the capsule 
and removing such other obstacles as might be found. When the legs were 
in position for the plaster cast, it was found that the left leg, like the right, 
gave the test condition of resistance to extension of the leg, and led the 
operators to believe that the head on this side also rested on the acetabulum. 
The error in this respect was demonstrated at the post mortem. Both legs 
were then placed in the position of hyperabduction and hyperextension 
("frog position"), and plaster of Paris applied by Drs. Dolson and Taggart. 

The following notes are given by Dr. C. A. Dexter, the house 
surgeon: — * 

The child was brought up from clinic at half-past twelve o'clock. The 
pulse was rather weak and rapid, and atropine sulphate, 3 mg. {^ grain), 
and strychnine sulphate, 2 mg. (^ grain), were given hypodermically and 
external heat applied, and the child reacted very well. On coming from under 
the influence of ether about two hours later, appeared to be in fair general 
condition. Later in the afternoon complained of some thirst, but not so 
much as the average ether patient. Was a little restless, but not so much 
as the usual case of a reduction by the same method. Was not nauseated, 
and did not vomit during the afternoon. About 9 p.m. vomited about two 
ounces of a dark brownish fluid, and once or twice during the night after 
this. Had stimulation during the night. After 10 p.m. the child became de- 
lirious, the delirium being of a mild talkative character and continuing through- 
out the night. At 8 a.m. the temperature was down to 07^, and external 



254 



CONGENITAL DISLOCATION OF THE HIP. 



heat was applied. Pulse was somewhat rapid and weak, and coffee and whis- 
key by enema, atropine and strychnia hypodermically, were given. The 
child apparently had begun to react, the pulse getting stronger. Was now 
perfectly conscious, and said that she was not in any pain. 

At 9 A.M. Professor Wilson was telephoned for, and arrived ten minutes 
later. Instruments were in readiness for saline infusion, but the child's con- 
dition became so rapidly worse that an opportunity to use them was not 
given. 

At 9.35 A.M. her condition seemed somewhat improved. 

At 9.40 A.M. there was a marked change: breathing suddenly became gasp- 
ing and superficial, pulse absent at the wrist. Stimulation was again used 
hypodermically; but the breathing quickly became worse, the heart-beats 
weaker, and with a few convulsive gasps the child died at 9.45 a.m. 

TSMPSRATUBB ChABT. 



Date. 


Hour. 


ReSP. 


Pulse. 


Temperature. 


March 17. 


4 P.M. 


20 


90 


98.40 


" 18. 


8 A.M. 


20 


80 


97.0° 


;; 18- 


1P.M. 


32 


100 


98.9" after operation. 


" 18. 


3 P.M. 


32 


112 


101.0^ 


" 18. 


6 P.M. 


36 


104 


101.40 


•• 19. 


8 A.M. 


38 


182 


96.40 


•• 19. 


9 A.M. 


40 


106 


99.40 


•• 19. 


9.40 A.M. died. 









In the light afforded by the very careful post-mortem exami- 
nation by Dr. Coplin in the presence of the staff of the orthopedic 
department, it may be noted that this was a case in which re- 
placement could not have been secured without removing the 
ligamentum teres, and that there was no way of predetermining 
the existence of the obstacles to the bloodless reposition. 

The main factor was the length and size of the ligamentum 
teres, which more than filled the acetabulum on each side, and 
therefore the sign which indicates reduction — that is, the slip- 
ping out of the head from the acetabulum as the leg is brought 
into an extended position — was absent. While this one factor 
(i.e., the ligamentum teres) was sufficient to have prevented 
reduction, the very thick capsule was elongated and had a 
tendency to fold in between the head and the acetabulum again, 
preventing the clear sound that occurred in other cases when 
the head, it is believed, entered the acetabulum. On both sides 
the articulating surface of the head was found placed above 
the posterior rim of the acetabulum, in which position it was 



H. A. WII.SON AND J. T. RUGH. 266 

placed at the time of operation, and was, therefore, decidedly 
anterior to the position which it had formerly occupied on the 
dorsum of the ilium. Just when or how the three factors oc- 
curred it is impossible to determine; for, while something was 
felt by the operators which was unusual, it did not partake 
of the nature of breaking bone, but closely resembled tearing 
fibrous tissue, and was so considered at the time of operation. 
The tearing soimd was communicated to the operator who was 
holding the pelvis as well as to the one who was manipulating 
the left leg. It was a diffused soimd, and its origin could not 
be located. Twice this occurred, but a third fracture which 
was foimd post mortem cannot be accoimted for. The bone 
ends in all three fractures were in close apposition, clearly indi- 
cating that, if death had not ensued, repair would have taken 
place in favorable position. That no fractures occurred upon 
the left side is due to the fact that efforts at reduction ceased 
in about one-half the time spent upon the right leg in realiza- 
tion of the inexpediency of continued efforts. The torn skin 
over the adductor tendons was accepted as an indication of the 
low vitality of the patient, as this did not occur m any other 
case, although several had had ecchymotic spots of quite large 
size for varying periods of from one to two weeks. 

As to the force used, it can only be compared with other cases, 
and may be stated as having been skilfully applied, and was 
much less and for a shorter time than in some of the other cases, 
And especially so in contrast to the fourth patient upon whom 
Lorenz operated. The forcible manipulations appeared to be 
suitable to the conditions, and there was no recognizable coun- 
ter-indications. The previous condition of the child gave no 
distinct evidence of her deficient vitality; and it would seem as 
though the methods employed at reduction were less respon- 
sible for the death than the anaesthetic, although the entire 
procedure must be considered. 

The pathologic conditions found in the limgs and kidneys, 
which gave decided indications of very recent origin, could be 
caused by ether ana^thesia for one and one-half hours. Pneu- 
monia following ether is sufficiently common in cases in which 



256 CONGENITAL DISLOCATION OF THE HIP. 

the operative procedures are of a mild character; and whether 
acute nephritis is likewise a sequel of ether intoxication is still 
a disputed point with pathologists, but the evidence in this 
case is strongly affirmative. 

While the condition of the patient did not indicate shock at 
the cessation of reduction manipulations, it was felt that 
the patient should be most critically safeguarded in every re- 
spect. When Dr. Schwartz, the official anaesthetizer of the 
department, was obliged to leave at the beginning of the ap- 
plication of the plaster cast, it was deemed expedient for Dr. 
Wilson to take his place while Drs. Dolson and Taggart applied 
the plaster bandages, with Dr. Rugh maintaining correct posi- 
tion of the legs. This disposition of the responsibilities is a 
satisfaction to all concerned, in that it is believed that every- 
thing was done to secure a favorable recovery in this case. 

The full details of the post mortem by Dr. Coplin are here 
given as an essential feature; and their value is enhanced by the 
disinterested manner in which the report is made, hoping that 
the conditions, methods, and results will be of service in guid- 
ing others in cases of this kind. 

Pathologic Report. 

Autopsy protocol, caae of B. D., female, seven years, white. Dra. H. Au- 
gustus Wilson and J. T. Rugh, siu-geons. Died March 19, 1903, at 9.45 a.m. 
Autopsy held March 19, 1903, at 1.45 p.m. 

Anatomic Diagnosis. — Bilateral congenital dislocation of the hip. Perfo- 
rate foramen ovale. Persistent th3nnus. Atheromatous arteritis of aorta 
and coronary trunks. Acute catarrhal tracheitis. Acute catarrhal bronchitis. 
Acute catarrhal pneumonia. General tuberculous lymphadenitis. Acute 
difiFuse hemorrhagic nephritis. Latentor obsolescent rachitis. 

External Examination. — ^The body is that of a fiurly well-nourished female 
child. Rigor mortis \a quite marked in the upper extremities and the calf 
muscles, but is slight in the muscles of the thigh. There is marked suggil- 
lation on the posterior aspect of the body, neck, head, and arms. The thighs 
are flexed at right angles to the body in the axillary lines, and the legs at 
right angles to the thighs. The thighs and pelvis are encased in the plaster 
dressing commonly used after bloodless operation. This is removed in the 
usual manner, using every precaution to prevent any alteration in the rela- 
tion of the enclosed parts. In spite of every care there was some movement 
of the right femur; and it was thought possible that it might have been mis- 
placed, although subsequent findings did not support the view. 

From the symphysis to the extreme margin of the right inner condyle 



H. A. WILSON AND J. T. RUGH. 257 

of the femur is 24 cm: on the left side the distance between correspond- 
ing points is 32 cm. The circumference of the right thigh, 8 cm. above the 
inner condyle, is 20 cm: 22 cm. above the inner condyle it is 29 cm. The 
circumference of the left thigh, 8 cm. above the inner condyle, is 19 cm., 
22 cm. above the inner condyle is 28 cm. The following external marks are 
present upon the right inferior extremity: On the inner aspect of the ankle, 
posterior to the malleolus, are a number of ecchymotic spots, petechial in 
character, distributed over an area of 4 cm. in the axis of the limb, and 3 
cm. transversely. From this point downward the superficial veins are con- 
spicuous, but not palpable, and clearly not thrombosed. Five centimetres 
above the inner condyle is a pinkish, ecchymotic area 1.7 cm. in length in 
the axis of the limb, and 5.5 cm. circiunferentially. From the lower third 
of the thigh upward, on the anterior surface, the skin shows pinkish-red 
mottling almost or quite to the junction of the skin covering the pelvis. This 
mottling is also present on the inner surface, but less marked posteriorly. 
Five centimetres from the S3nnphysis, beginning 2 cm. below Poupart's liga- 
ment and extending downward, is an abrasion 2.8 cm. in length by 1 cm. 
in width: 5.5 cm. from the sjmiphysis is a second abrasion nearly parallel 
with the first, 2.5 cm. in length and 1 cm. in width. At these points the epi- 
thelial layers of the skm are stripped and possibly also the connective tissue 
layers, although the subcutaneous tissues do not protrude or the skin retract : 
the eroded areas are covered by glazed lymph, through which the ecchy- 
motic bases can be seen. The areas just described are in a laxger field of 
discoloration, greenish-purple with darker purplish mottling, and extend- 
ing from a point 2.5 cm. to the right of the sjnnphysis to a distance of 15.5 
cm. from the symphysis and becoming continuous with the irregular mot- 
tling referred to as present in the lower part of the thigh. The axis of this 
area corresponds to the coiu^e of the femoral artery; and the area measures, 
transversely, 9.5 cm. It extends above Poupart's ligament 3 cm., and from 
the median line to the anterior superior spine. The skin of the perineum 
and the cutaneous structures of the vulva are possibly a little redder than 
normal, while the mucosa of the vulva is suffused with blood and purplish 
in color, the suffusion being most marked around the urethral orifice. The 
large area of discoloration already described on the right thigh is soft and 
almost fluctuating near its centre and quite resistant, almost dense at the 
margin: at the base, near Poupart's ligament, it is quite dense. 

Left extremity: near the ankle are areas of discoloration, petechial hem- 
orrhages and prominent veins essentially of the same kind as described on 
the opposite limb. On the inner aspect of the leg just within the margin 
of the tibia is an old ecchymotic patch 7 cm. below the upper end of the tibia. 
It is purplish with greenish-yellow margins, oval in outline, and possesses 
a maximum diameter of 1.8 cm: 5.5 cm. above the inner condyle is a pink- 
ish-red area of discoloration, the long axis being transverse to the long axis 
of the limb, 6 cm. in length and 1.4 cm. in width. Just over the patella is 
a small ecch3nnosis 0.7 cm. in diameter. The anterior surface of the thigh 
shows the same pinkish mottling already described as present on the op- 
posite limb. Four and seven-tenths centimetres to the left of the pubis 
is an irregular laceration of the epidermis and derma, 3.7 cm. in length, 0.4 



258 CONGENITAL DISLOCATION OF THE HIP. 

cm. in width, bridged here and there by fragments of the deeper layers of the 
skin and marginated by smaller fissured lacerations, 1 to 2 cm. in length. 
The long axis of this area is parallel to the axis of the trunk. It is situated 
near the base of a large purplish-green area, irregular in outline^ beginning 
3.2 em. from the symphysis and extending in the axis of the limb 9.5 cm., 
and in the axis of the trunk 9.5 cm. This area of discoloration extends 2 
cm. above Poupart's ligament, at which point it is 4 cm. in length (this latter 
measurement made parallel with Poupart's ligament). The area is less 
tense than the corresponding area on the opposite side, but similarly colored 
and with denser margins. 

The lower part of the abdomen is flat, or nearly so, the costal margins promi- 
nent, and the epigastrium slightly bulging. There is a suggestion of a rachitic 
rosary. The sternal ends of the clavicles are slightly enlarged, and the 
sternoclavicular attachments very relaxed, almost permitting dislocation. 
The shoulder and wrist joints, and, to a lesser degree, the elbow, knee, and 
ankle joints are relaxed: the amount of lateral movement at the wrist and 
shoulder joints is strikingly in excess of the normal. The lower end of the 
radius and tibia (right and left) are apparently enlarged, but not conspicu- 
ously so. We were not allowed to incise them: they may have been slightly 
rachitic. 

The forehead is prominent, the calvarimn large, suggesting the general 
contour of a slightly hydrocephalic head, the lips are purplish and dry, the 
pupils are dilated and the eyes slightly sunken. 

The axillary, cervical, and submaxillary lymph-nodes are notably enlarged: 
in the axilla, nodes possessing diameters of 1.5 cm. can be felt. The anterior 
cervical nodes are smaller, but distinct chains can be palpated along the pos- 
terior borders of the sternocleidomastoid muscle. Under each mandibular 
angle is located a node approximately 1 cm. in diameter. As none of these 
areas was subjected to dissection, the measurements given could be estimated 
only. The tonsils appear slightly enlarged. The oral mucosa is pale, but 
without any discernible lesion. 

Internal Examination. — The subcutaneous fat over the chest and abdomen, 
along the median incision, is scanty, but normal in color and texture. The 
musculature of the chest and abdomen is normal in color and texture, but 
rather poorly developed. 

The peritoneum is normal, the transverse colon considerably distended. 
There is purplish discoloration of the tissues of all the right half of the pelvis 
extending down behind the rectimi, along the anterior sacral border into the 
broad ligament, slightly over the posterior part of the bladder and upward 
anteriorly 4 cm. above Pourpart's ligament, corresponding to the already 
described area of discoloration on the external surface: laterally, on the 
right side, the purplish shading reaches a point just above the head of the 
colon. This irregular area of purplish mottling and suffusion is not palpa- 
ble, although its ecchymotic character is fairly marked. There is slight 
ecch3nnosis in the neighborhood of the femoral ring of the left side. 

The pleurae are dry, as is the pericardium. Both serosae are normal. 

The th3rmus is exceptionally large, extending anteriorly below the middle 
of the heart, latterly into the mediastinum, and above to and partly occupy- 



H. A. WILSON AND J. T. RUGH. 259 

ing the suprasternal notch. It is an arrowHihaped organ, 9 cm. in length, 
5 cm. in width, and 0.7 cm. in thickness. It extends along the trachea as 
a single body for 1.5 cm., then divides into two equal parts more or less cylin- 
drical in outline and 2 cm. in length that are projected upward along the 
sides of the trachea. Weight, 20 grams. 

Histologically,* the organ shows no specially noteworthy abnormality. 
The secondary lobules are much larger than normal in a child of this age. 
The increased volume seems to depend upon persistence or hyperplasia of 
the lymphoid elements. The differentiation between periphery and cortex 
is ill-defined. The bodies of Hassall (concentric corpuscles) are unusually 
abundant. At a few points rhexis has occurred, and small areas of inter- 
cellular hemorrhage, not at any point large or abundant, are occasionally 
seen. Lipomatous substitution of the adenoid tissue is not at any point 
in progress. It might be well to note that in many cases persistence of the 
th3rmus has been found as a part of the morbid anatomy of rickets. 

Heart: The cavities of the right side are distended and occupied by clots, 
which for the most part are white or the color of chicken fat, with su- 
perimposed purplish coagula. The left side is empty. The valves and 
orifices of the right and left sides i^pear normal, except as noted below. 
The foramen ovale is obliquely patulous, the opening barely transmitting 
a grooved director. It is 0.3 cm. by 0.25 cm. in size. There is a small patch 
of atheroma on the ventricular aspect of the anterior leaflet of the mitral. 
The myocardium is pale, but fairly firm in texture. Weight, 85 grains. 

Histologically, the myocardium shows no conspicuous abnormality. Oc- 
casional fibres are slightly granular: fat is absent. The smaller coronary 
branches are not altered. 

The presence of even a small atheromatous plaque in the mitral leaflet 
in one so young indicates the existence of some noxious influence, possibly 
S3rphili8, or it may be rickets, as the relatively smaU heart and thin walled 
vessels would seem to refute any suggestion that the alteration here noted 
depended upon heightened vascular stress. The change described below 
as present in the aorta also supports either of the former views. 

The aorta just above the aortic orifice is the seat of a diffuse yellowish 
infiltration that surrounds the coronary arteries, completely encircling the 
aorta, and has thickened the aorta, particularly in the neighborhood of the 
coronary orifices. The thickening of the aortic wall is at the expense of 
the lumen. The right coronary artery is surrounded by a distinct zone of 
such infiltration. Other macroscopic evidence of arterial disease was not 
found beyond the aorta. 

Histologically, longitudinal and transverse sections of the infiltrated aorta 
show the usual changes of an atheromatous patch. The intima is intact 
and slightly thickened: the subintimal elastica fragmented at the margin of 
the area and not demonstrable near its centre. The media is partly involved, 
and between the altered media and intima is a necrotic accumulation contain- 
ing cellular debris, fragments of elastica and granular detritus. Evidences 

* For convenienoe in reference the histolqtry of the organ is incorporated with the 
autopsy record. The techDic has been practically the name for all. Selected blocks 
of tiasae were fixed in Bensley's solation, washed, dehydrated, infiltrated with 



paraffin, sectioned, and stained by approved laboratory methods. The find: 
each instance are epitomized in this report. 



260 CONGENITAT. DISLOCATION OF THE HIP. 

of calcific change are wanting. Sections so oriented as to include the coro- 
nary exit show that the process extends but a short distance (1 nun. or 2 mm.) 
into that vessel. As yet the sectional area of the coronary orifice has not 
been altered. 

Left lung: The superior lobe contains a munber of small areas of atelectasis 
5 nun. to 10 mm. in diameter, irregular in outline, evidently recent. In the 
base of the lower lobe anteriorly is a larger, partly collapsed area, not, how- 
ever, airless, measuring 0.5 cm. by 1.5 cm. The subpleural tissue posteriorly 
is oedematous and the seat of numerous petechial hemorrhages: similar hem- 
orrhages are also present on the diaphragmatic surface and along the anterior 
margin of the organ. Centrally and toward the upper portion of the lower 
lobe is a purplish-red area, 2.5 cm. in length and 1 cm. in width, that 
appears quite airless. Toward the base are niunerous smaller areas pos- 
sessing the same characters. Areas of solidification varying in size from 
0.5 cm. to 1 cm. are also present in the upper lobe. Weight, 110 grams. 

Right lung: This organ is, in a general way, the seat of changes essentially 
the same as those noted as present in the left. They are a little more marked 
posteriorly, and less evident at the apex and along the anterior and dia- 
phragmatic aspects. Weight, 125 grams. 

The larger bronchi of both organs are the seat of cedema and redness of 
the mucuous membrane, and often contain a frothy red mucus. 

There is a mucosanguinolent frothy fluid in the trachea. 

Histologically, the changes present in the air passages and lungs may be 
summed up as (1) catarrhal bronchitis, (2) bronchiolitis, (3) lobular pneu- 
monia. None of these is very advanced, although all the blocks examined 
show the changes. The mucosa of the trachea and bronchi, large and small, 
shows epithelial desquamation, serous and leukocytic infiltration of the sub- 
mucosa of the large tubes and peribronchial tissues of the smaller. Here 
and there throughout the sections are lobules or parts of lobules inundated 
with mucus or overdistended by compensatory efforts. There is very little 
interalveolar cellular infiltration. 

Properly stained preparations show the presence of an organism possess- 
ing the morphology and tinctorial characters of the pneumococcus. The 
bacteria are not numerically conspicuous, although widely distributed. 

The peribronchial and mediastinal lymph-nodes, and especially those 
situated at the bifurcation of the trachea, are enlarged and slightly matted 
together. The larger masses vary in size from 0.5 cm. to 1.5 cm. in diam- 
eter, are tense, evidently swollen and, on section, contain grayish dotlets 
1 mm. to 2 mm. in diameter, possessing the macroscopic characters of tuber- 
cles. The histology of these glands will be given below with other lymphad- 
enoid groups. 

The spleen is relatively firm, its pulp of normal density, possibly a little 
paler than normal. The adenoid groups are not perceptibly changed. Weight, 
55 grams.* 

The adrenals are normal in size and general appearance. 



* Unfortunately, the pieces of spleen, adrenal, stomach, daodennm, and pancreas, 
were not set aside for histoloffic stadv or were mislaid. There is no reason to sap- 
pose that a histologic stndy oi any of these orsrans would throw additional light on 
the cause of death: possioly it might have shown lesions oorroboratiye of the gen- 



H. A. WILSON AND J. T. RUGH. 261 

The left kidney has retained its foetal lobulation: it is rather h3rper8emic, 
soft and cloudy. The cortex is slightly swollen; the labyrinthian areas 
hypersemic; the malpighian bodies not more evident than usual. The cap- 
sule is easily detached; the stripped surface is red and oedematous; the red- 
ness is rather punctate. The pelvis is normal. Weight, 60 grams. 

The right kidney shows essentially the same changes as the left. Weight, 
55 grams. 

The ureters are normal. The right ureter can be traced downward through 
the area of hemorrhage; there is no evidence of pressure on it within this area; 
the mucosa is normal. 

Histologically, the kidneys manifest no evidence of any old lesion, but show 
to a most marked degree the presence of alterations of recent origin. The 
labyrinthian areas are frequently the seat of irregular inter- and intratubular 
hemorrhage. The hemorrhages are recent, the extravasated blood un- 
altered: tubules are frequently distended with blood-casts. The epithe- 
liimi of the convoluted tubules is often granular and stains defectively: at 
no point has it desquamated. The malpighian tufts are frequently engorged, 
but in exceptional instances only is a tuft found in which free hemorrhage 
has occurred. 

Bladder: With the exception of the subserous suffusion, already mentioned 
as present under the peritoneal coat, the organ shows no gross lesions. Ure- 
thra normal, except at the external orifice, as previously described. 

The internal and external genitalia show no noteworthy abnonnality not 
already recorded. 

The oesophagus, stomach, and intestines show no important change. The 
agminated patches are inconspicuous, the solitary follicles prominent. The 
mucosa of the stomach and lower end of the oesophagus show slight erosions, 
thought to be evidences of post-mortem digestion. 

The pancreas is partly annular, extending about half-way roimd the duo- 
denum. It shows no gross lesion. Weight, 45 grams. 

Liver: The biliary passages are patulous and normal. The gall bladder 
lightly distended by apparently normal bile. The superior surface of the 
right lobe of the liver shows several areas grayish-white in color, irregular 
in outline, 0.2 cm. to 0.5 cm. in diameter, apparently focal necroses. Pos- 
teriorly, the organ is lightly congested. There is no special noteworthy 



The mesenteric glands are notably increased in size. Some of the largest 
are ovoid, measuring 1.5 cm. by 2 cm.: they are fairly numerous at many 
points, but particularly so in the sigmoid area. They are equally enlarged, 
though less abundant in the ileocecal region. The enlarged nodules are 
often tense, the exterior mottled, showing areas of grayish or yellowishr 
white on a rather pinkish background. The investing peritoneum is smooth 
and transparent, and the nodes easily freed from the adjacent tissue. On 
section they are grayish, succulent, and contain minute whitish areas that 
suggest tubercles: at points there is a suggestion of caseation, but nowhere 
is this change striking. 

The retroperitoneal enlargements are evident, but less abundant. On 
section these nodes show the same general characters as those in the mesentery. 



262 CONGENITAL DISLOCATION OF THE HIP. 

MacroBcopically, the axillary, cervical, submaxillary, mediastinal, peri- 
bronchial, mesenteric, and retroperitoneal lymph-nodes show essentially 
the same features. The following histologic description is based on exami- 
nation of. the mesenteric, mediastinal, and peribronchial S3rstems. 

Histologically, the l3anph-nodee manifest those changes characteristic 
of a moderate degree of widely disseminated infection by the tubercle bacillus. 
Distinct caseation is scantily present in occasional nodes from all the systems 
examined: it seems apparent that the peribronchial and mediastinal groups 
are most involved; they are also the seat of mixed infection. Many nodes 
are not caseous, nor do they contain macroscopic nor microscopic tubercles, 
although some of them contain tubercle bacilli. In such nodes the peripheral 
and follicular sinuses are distended by uninuclear leukoc3rtes and desqua- 
mating endothelial cells from the walls: the medullary cords are also closely 
packed. Occasionally in the peribronchial system fibrin can be demon- 
strated, indicating an acute and active character in the process. In some 
of these glands pneimiococci were identified. 

Dissection of the thighs and pelvis: From the median incision two incisions 
are extended laterally to about the centre of Poupart's ligament and then 
downward on the anterior surface of each thigh, following, as nearly as pos- 
sible, a line parallel with the axis of Scarpa's triangle and extending beyond 
the area of notable discoloration. Inoculations are taken from beneath the 
deep fascia, and finally the arterial and venous trunks partly exposed. Water 
is forced through the abdominal aorta into each iliac artery until the vessels 
distend fully. The water oozes from the adjacent infiltrated tissues, while 
the arterial trunks become tense. The veins are similarly tested, and with 
like results. These tests satisfactorily establish that none of the large trunks, 
or important branches, are lacerated. That the vessels are patulous is also 
established by opening them at Hunter's canal and observing that the water 
flows through without obstruction: the thin-walled femoral and iliac veins 
can be seen to be free from any obstructing or mural thrombus. 

The dissection is now extended, exposing the muscles of the thigh and 
finally the hip joints. The anterior crural nerves and their branches are 
macroscopically intact. There is considerable difficulty in identif3dng the 
various anatomic structure on account of the extensive hemorrhagic infiltra- 
tion to which the superficial discoloration already described evidently is due. 
The condition on the right side will be described in det^, followed by an 
account of the left side. 

In the cellular and fatty tissue beneath the deep fascia are loculi contain- 
ing coagulated blood: these small irregular cavities vary in size, the largest 
scarcely exceeding 1.5 cm. in its maximum diameter. Evidently, a number 
of these spaces may communicate either directly or indirectly. The total 
amount of blood extravasated cannot be estimated with any degree of accu- 
racy, but is considerable. The distinct cavities containing blood are in the 
neighborhood of the femoral sheath and beneath the sartorius muscle. (Later 
a few small loculi were found behind the bone: they were not, however, 
of notable size.) The inner border of the sartorius and the anterior part of 
the adductor longus are suffused to a moderate degree. The muscles forming 
the floor of Scarpa's triangle (iliacus, psoas, pectineus, and, in part, the long 



H. A. WILSON AND J. T. RUGH. 



2G3 



and short adductors) are also sufifused with blood. The tensor vaginae femoris 
and gkiteal muscles contain but a few points of interstitial hemorrhage. 
The intense purplish-black staining of the muscles renders it quite impos- 
sible to determine accurately just how much, if any, real laceration is present. 
There are valid objections to complete dissection of the limb, but a fairly 
exhaustive examination of the exposed muscles fails to disclose any exten- 




Kigrht hip joint. A, thickened capsular ligrament. B, capsular ligament at point of 
maximam thickening. C, ligamentum teres occupynis the ^eater part of the 
acetabulum ; the notable elongation is shown by the relaxed ligrament extending: 
to the head of the femur. D, the leader from D is over the line of fracture in the 
neck of the femur; the point of separation does not show, as it is covered by 
periosteum. E, fracture of ischium: the periosteum has been divided, show- 
mfiT oblique line of separation. F, second fracture of the ischium ; the perios- 
teum is intact and the line of fracture indicated only by the sligrht darkening 
due to subperiosteal hemorrhage. 



sive single or ma^ive laceration, although what might be termed a fibrillar 
dissociation is present in nearly all the dissected muscles already mentioned. 
The solutions in the continuity of solid muscle bodies are oblique, mixed 
longitudinal and slightly oblique, but not directly transverse fissurings. The 
muscles are notably flaccid, probably as a result of post-mortem rigidity and 
coagulative changes in the ex-travasated blood. 

If there be any laceration of branches of the internal iliac artery, a fairly 
comprehensive examination of the areas in which they are distributed, re- 
enforced by the hydrostatic test already described, fails to disclose it. The 
intrapelvic suffusion previously mentioned is found on incision to be in the 
cellular tissue immediately beneath the serosa only, and, so far as can be 
determined, has reached the areas mentioned by infiltration from the neigh- 
borhood of the femoral canal. 



264 CONGENITAL DISLOCATION OF THE HIP. 

The hip joint: The head of the femur seems to be almost in place, but on 
closer examination, after incision of the capsular ligament, is found to be 
resting with the margin of the articular surface on the posterior-superior 
brim of the acetabulum. The head, apparently as a result of fibrous adhe- 
sions, cannot be replaced within the joint, although no degree of force was 
used in the attempt. The capsular ligament and ligament um teres are re- 
laxed. A slight effort at straightening the limb is followed by the immedi- 
ate displacement of the head of the femur upward and backward. The 
innominate bone just back of and above the acetabulum is smootli, and seems 
a little more dense than elsewhfere. Realizing that a careful studj^ of the 
bone and joint at the necropsy would not be possible, the ilium was divided 
just below tlie inferior curved line and also through the body and ramus 
of the pubes near the angle and the femur sectioned just below the trochan- 
ter. Recognizing the presence of fractures, great care is necessary in re- 
moving the specimen; and force must be avoided, in order to prevent any 
further alteration in the architecture and relation of the structures to be 
examined. This specimen was removed to the laboratorj^ and partly dis- 
sected by Dr. AUer G. Ellis, who submits the following detailed description : — 

The specimen as removed consists of those portions of the right innominate 
bone and upper extremity of the right femur that include all the structures 
entering into the formation of the right hip joint. The capsular ligament 
has been incised along the anterior and superior margin of the acetabulum: 
it is much thicker posteriorly and externally than below^ and in front. The 
acetabulum is slightly flattened, measuring 2.75 cm. in the vertical and 2.25 
cm. in the horizontal axis. The greatest depth of the cavity proper is 0.7 
cm. The ligamentum teres is 5.5 cm. long, 0.4 cm. wide, and 0.2 cm. thick 
at its middle, expanding at both ends. The acetabular insertion is expanded 
so that it occupies all of the anterior third of the cavity. In addition to this 
an extension 0.3 cm. thick spreads over about half of the remaining two- 
thirds of the floor of the acetabulum. The ileo-femoral ligament is indistin- 
guishable from the capsular, and the cotyloid and transverse ligaments can- 
not be exposed without undesirable mutilation of the specimen. The head 
of the femur is slightly flattened antero-posteriorly. There is a lentil-shaped 
area of flattening of the articular surface that corresponds to the point of 
attachment of the ligamentum teres. The ligamentum teres is inserted on 
the upper portion of an almost plane surface that measures 1.75 cm. by 1.5 
cm. This flattened surface corresponds to a similar area on the posterior 
margin of the acetabulum, the latter area being formed partly of the bony 
wall of the acetabular cavity and partly by compressed ligamentous tissue. 

There is an intracapsular fracture of the neck of the femur. The line of 
separation passes obliquely across the neck of the bone, and at the upper 
border almost reaches the juxta-epiphyseal line of the head. At the lower 
border it is 1.5 cm. from that line. The periosteum for some distance on 
either side of the line of fracture has been separated from the bone by sub- 
periosteal hemorrhage. There is a fracture of the ischium extending through 
the body of that bone in an ahnost horizontal plane. The highest point 
of the line of separation is external, where it is approximately 0.5 cm. below 
the acetabular margin. Subperiosteal hemorrhage is present around this 



H. A. WII.SON AND J. T. RUGH. 265 

fracture. There is also a second fracture of the ischium passing transversely 
through the ascending ramus at a point 0.8 cm. above the lower boundary 
of the obturator foramen. No fragment in any of the fractures shows the 
slightest displacement: there is no perceptible separation, and the alight 
periosteal hemorrhage is the most conspicuous feature present at the line of 
separation. The periosteimi holds the fragments in accurate apposition. 

The left side differs from the right in degree of reposition, but in no essen- 
tial anatomic character. The hemorrhagic infiltration is very much less, 
but the distribution in the thigh is practically the same as on the other side. 
There are a few loculi similar to those mentioned as present on the right and 
distributed along the course of the femoral sheath. The intermuscular and 
intramuscular suffusion is nothing like so marked as that seen on the opposite 
side. The head of the femur is scarcely more than raised on the brim of the 
acetabuliun upon which the articular surface rests. The condition of the acet- 
abulum, head of femur, and ligaments, seems the same as on the opposite 
side, and a repetition of the description does not seem necessary. There is 
no noteworthy difference between the periarticular structures on the two 
sides, except that on the left fibrous adhesions are more conspicuous and 
the head of the bone seems more firmly anchored. This difference is prob- 
ably due to less thorough dissolution of adhesions possibly originally equally 
firm on the two sides. No fractures are present on the left side. After sec- 
tion of the almost unresisting muscles it was foimd almost impossible to place 
the head of the femur in the acetabulum, although the capsular ligament 
is opened anteriorly and two fingers placed in the joint as aids to reposition. 
The resistance to restitution to position seems to be great thickening and 
dense fibrous adhesions posteriorly, as on the other side the bulky ligamen- 
tum teres occupies the cavity of the acetabulum. No specimen from this 
side was preserved. 

Permission to examine the central nervous system was not obtained. 

Bacteriology. — Inoculations on agar and into bouillon were made from the 
areas of hemorrhagic infiltration and loculi of blood in the thighs, also from 
the pleuras, pericardium, blood of the heart, spleen, and liver; but no growths 
were observed. Tubercle bacilli, as already noted, are present in many of 
the lymph-nodes; and an organism believed to be the pneumococcus is 
present in the sections of the lung and peribronchial lymphatics. The last- 
named organism not infrequently fails to develop in cultures made from tis- 
sues in which it can be demonstrated by staining methods. 



III. 

THE FORCIBLE REPOSITION OF CONGENITAL LUXA- 
TION OF THE HIP. 

GWILTM G. DAVIS, OF PHILADELPHIA. 

The attempts at forcible reposition of congenitally luxated 
hips have given rise to so many accidental traimiatisms that 
the question has arisen as to whether, in order to avoid bring- 
ing the treatment into disrepute, it is not appropriate to advo- 
cate more conservative measures. 

That it is both desirable and proper to use a certain amoimt 
of force in this as in other orthopedic measures is self-evident, 
and its employment in the reduction of congenital luxations 
is just as necessary as it is in traumatic ones and, rarely per- 
haps, even with the greatest care, a femiu* may be fractured; 
but the question is. Has not the use of force been carried too 
far? 

When Paci was evolving his method of forcible reposition 
from 1887 to 1894, he was evidently at times employing consid- 
erable force, and fully appreciated its dangers. He laid much 
stress on using the greatest care and slowness in making the 
reposition, because he stated that fracture of the thigh might 
otherwise be produced, which accident, he said, had already 
occurred. When Professor Lorenz, after seeing Paci demon- 
strate his method of forcible (now sometimes called bloodless) 
reposition at the time of the International Congress in Rome 
in 1894, published and demonstrated in 1895, and later his 
own mode of procedure, it was characterized mainly by the 
great force advocated. What Paci attempted by compara- 
tively mild and more or less gradual methods Lorenz sought 
to accomplish by violence. The earlier descriptions and reports 
of his manipulations showed that such an amoimt of force was 
used and so many serious injuries inflicted as to cause me to 

Presented at the Seventeeth Annual Meeting of the AsBOciation, Washington, 
D.C., May 11-14, 1903. 



G. G. DAVIS. 267 

view his modifications of Paci's procedures with distrust, and 
doubt their necessity. When in 1900 Professor Lorenz issued 
the second edition of his volume on congenital luxations of the 
hip, he stated that in 450 cases he had had 3 deaths, — 1 was 
from chloroform narcosis, the other 2 were apparently due 
to the manipulations, for they occurred sixteen and twenty- 
four hours later. There were also 11 cases of fracture of the 
neck of the femur, 1 of the pubic bone, 1 of the iUum, 3 par- 
alyses of the perineal nerve, 7 of the anterior crural, besides 
some of the sciatic, and 1 total gangrene of the lower extremity. 
Minor traumatisms, causing stiffness of the joints and the serious 
ruptures described by Narath, also occurred. 

Heusner, of Barmen, has recently stated that he and Hoffa 
have had even more serious results. Hoffa in the German 
Congress of 1899 stated that he had had tearing of the soft 
parts, vulva, urethra, fractures and separation of the epiphyses, 
paralysis of the sciatic and anterior crural nerves, and suppu- 
ration of the hematomas which formed at the site of rupture 
of the adductors. He even lost one case, a child of six years 
of age. It may be urged that these injuries occurred early 
in the development of the method of forcible reposition and 
in old cases. This is only partly true, because Heusner's article 
appeared late in 1902 (Zeitschrift fur orthopaedische Chirurgie) ; 
and it is a well-known fact that the most difficult cases are not 
always the oldest ones, — one of the worst in Philadelphia was 
only four years of age, — ^also that these accidents appear to 
be still recurring, and new instances are being continually 
brought to light. Wilson and Dinkelspiel state that in one 
of the cases operated on by Professor Lorenz himself in Phila- 
delphia the child was seized with convulsions, went into a state 
of stupor, the pulse became weak and rapid and could not be 
counted. This child fortimately recovered. Professor Lorenz 
is quoted as saying of this case that he considered shock and 
traumatism as the cause of the symptoms. Others who have 
followed his teachings have not escaped. I have recently 
heard of two additional deaths and another case of fracture 
of one thigh and paralysis of the opposite leg in a bilateral 



268 <X)NGENITAL DISLOCATION OF THE HIP. 

luxation, besides tearing of the perineum and other traumatisms. 
In order to appreciate what amount of force Professor Lorenz 
advocates and uses in his manipulations, the four cases oper- 
ated on in his public clinic in Philadelphia will illustrate. His 
routine method, as accurately as I can describe it, on that occa- 
sion was first to place the child on Kdnig's block, and, an assist- 
ant holding the pelvis, the thigh was abducted and extended, 
while pressure was made on the adductors near the symphyos 
until they were ruptured. The leg was then extended on the 
thigh and the thigh forcibly flexed on the abdomen until the 
heel laid alongside of the ear. Then the operator or his assist- 
ant made traction while the other held the pelvis. The child 
was then replaced on the block, and forced abduction and 
hyper-extension performed with the thigh at right angles to 
the body and the leg flexed on the thigh, the internal condyle 
pointing anteriorly and the toes laterally outward. This posi- 
tion I would call external rotation. These manipulations were 
repeated until the head moved to its new position. In the 
last case, after performing these manipulations in a child aged 
four years, and not succeeding, six times was extension made 
by assistants pulling on a skein of yam attached above the 
ankle, while counter-extension was accomplished by a sheet 
fastened to one comer of the table, the perinetun being pro- 
tected by a rabber pad. On one occasion there were three 
assistants pulling, the operator was pushing on the trochanter, 
another assistant helped to steady the pelvis, another gave 
the anaesthetic, and three were holding the table, — a force of 
eight powerful men (exclusive of the anesthetist) who were 
exerting their strength, directly or indirectly, on the tender 
tissues of a child four years of age. Between the tractions 
the patient was repeatedly hyper-extended over the block. On 
the last attempt the head moved slightly forward, and the 
operator stated that in this case he would be satisfied with a 
partial result. That the manipulations were not without a cer- 
tain amount of risk, even to the operator, was shown by the 
reported sequel of his having sustained a sprain of the wrist 
as a result of his efforts. 



G. G. DAVIS. .260 

While it is true that many of these severe injuries have oc- 
curred in the older cases, they are by no means confined to 
them. Their frequent occurrence apparently compelled Lorens 
to abandon the use of his screw traction, and instrumental 
traction has been discontinued by nearly all operators. The 
great increase in the niunber of accidents and severe injuries 
following attempts at reduction which has occurred since Pro- 
fessor Lorenz has given public demonstrations in this coimtry 
justifies a plea for a modification of the methods at present so 
generally used. Designating as ''bloodless" a method that 
tears the soft tissues, breaks the bones, produces hematomas 
extending from the middle of the thigh below to the imibilicus 
above, and at times kills the patient, seems to me to be a trifle 
facetious, and certainly savors more of sophistry than it does 
of truth. 

When we consider that the deformity is not a fatal one, and 
that in some it is not even a seriously disabling one, means 
of treatment wUch subject the patients to the serious risks 
of permanent injury or loss of life are not to be recommended. 

It therefore becomes a duty to see if the objectionable and 
dangerous features cannot be eliminated. With this object in 
view the following suggestions are offered: That the tendons 
of the adductor muscles at least be cut subcutaneously, and 
thus considerable traumatism and mauling of the soft tissues 
at this point be avoided. It appears to me to be unnecessary 
to resort to violent stretching movements in all directions, as 
a routine practice to loosen up the joint. It is a serious ques- 
tion as to whether by rendering the joint loose and flail-like 
they do not increase the fimctional disability and favor the 
tendency to displacement. In many cases, particularly the 
younger ones, replacement can be accomplished, as has been 
my experience, without such extensive tearing and stretchings. 
Violent tractions for immediate replacement, I believe, should 
be totally abandoned. Everything that can be gained by 
violent traction can be gained without risk by weight traction, 
with the patient confined to bed for a variable period of time. 
This has been demonstrated by Pravaz, Volkmann, Brown, 



270 CONGENITAL DISLOCATION OF THE HIP. 

Mikulicz, and others. Lorenz* characterized his own method 
as a traction method and Paci's as a circtunduction method; 
and he was right, but it is the latter which is the correct one. 
Forcible traction has no place in the immediate reduction of 
congenitally luxated hips. It is the agent which is mainly 
responsible for the traumatisms which are inflicted; and, if we 
are to avoid them, we must adhere more closely to the original 
teachings of Paci, which, as he stated, consisted simply in the 
application of the circumduction method of reducing trau- 
matic luxations. In this the thigh is flexed on the abdomen, 
followed by downward pressure on the knee with abduction, 
external rotation, and gradual extension. Pressure is made 
on the trochanter posteriorly while the limb is carefully ex- 
tended. Abduction is afterward maintained to an extent suffi- 
cient to prevent the head from escaping from its new position. 
Whether the thigh is completely flexed on the abdomen or only 
at right angles to the body, I think, is immaterial, but prefer 
the former. If the adductor muscles prevent the desired ab- 
duction, they can be tenotomized. This is not always neces- 
sary. 

To make the pressure on the trochanter, it can be done with 
the hand beneath or rested on a hard roll, as did Pravaz; the 
edge of the table, as did Paci; or Konig's block, as does Lorenz. 
If serious difficulty is experienced in attempting reductioui 
then, instead of resorting to increased force, I believe it better 
to confine the patient to bed with the limb abducted and with 
weight extension, if desired, for two to eight weeks or even 
longer, and then again attempt reduction. The loss of time 
occasioned to these children is insignificant compared with the 
importance of avoiding the dangers of violence. 

Rather than resort to the great force now at times employed, 
I believe it to be much better to incise and clear a way for the 
head of the bone. 

• Revue d'Orthopmdie, 1897. p. 143. 



IV. 
CASES OF CONGENITAL DISLOCATION OF THE HIP. 

GEORGE B. PACKARD; M.D. 

The following cases of congenital dislocation of the hip were 
operated upon by Professor Ix)renz in Denver, Oct. 28, 1902. 
Most of the cases have been under my observation smce that 
time. 

Case 1. — A. R., female, aged five. The dislocation was up- 
ward and backward, the top of trochanter being 1^ inches above 
N61aton's line. The reduction was accomplished by the usual 
manipulation. The spica was applied, and the child began to 
walk in about one week. Dr. Lorenz remarked at the time that 
the stability was poor. I removed the dressing six months 
after its application, and reapplied the spica. As far as I could 
judge, the head of the bone was in the anterior position. An 
X-ray picture was taken, by mistake, after the plaster was 
reapplied. I think, however, after a careful study of the pict- 
ure it shows the head of the bone below the anterior superior 
spine. 

Case 2. — C. H., female, aged six, was treated for one year 
by a brace which prevented weight-bearing. The dislocation 
was posterior, and reduced with considerable difficulty. Fear 
of fracturing the bone was referred to by Professor T^orenz 
from the fact that the leg had been deprived of functional use 
during the preceding year. The stability, however, was reported 
good. About six months from the time of operation I re- 
moved the dressing, and the head of the bone seemed to be in 
position. An X-ray picture was taken, and I think it shows 
without any doubt the head of the bone in the proper position. 

Case 3. — E. R., female, aged five. Posterior dislocation with 
one inch shortening. Reduction was accomplished compara- 
tively easy, and the stability reported good. May 3, 1903, 
the first spica was removed, joint examined, and an X-ray pict- 
ure taken which shows the head in position. 

Case 4. — J. M., male, aged five. Posterior dislocation, motion 
somewhat restricted. Reduction took place with a good deal 



272 CONGENITAL DISLOCATION OF THE HIP. 

of difficulty, but stability was pronounced good. A singular 
fact in regard to this case is that he has two brothers afflicted 
with the same deformity, one of them being double. A skio- 
graph shows the head a little above the acetabulum. 

Case 5. — J. M., female, aged five. This case presented the usual 
symptoms of posterior dislocation, and waa reduced with very 
little force. The a<;etabulTun was evidently very shallow, and 
with very slight motion dislocation would reoccm-. The spica 
was applied, and the patient has been walking since. The 
child lives in Wyoming, and has not returned for further dress- 
ings. I cannot therefore report on her present condition. 

Case 6. — ^J. T., female, aged nine. Reduction was attempted 
in this case notwithstanding the age, although the opinion was 
expressed at the time by Professor Lorenz that the result was 
very uncertain. After a great deal of force was used, partic- 
ularly in extension, abduction was attempted. This resulted 
in tearing the skin and subcutaneous tissues in the perin^eimi 
to such an extent that the operation was abandoned. The 
spica was applied with the leg in an abducted position. I have 
not seen this case since the operation. 

Sufficient time has not elapsed since the operations to deter- 
mine the ultunate results in these cases, but the present indi- 
cations are that Cases 2 and 3 will result in recovery and that 
Cases 1 and 4 will be displaced forward and upward. I cannot 
make any report on the present conditions of Cases 5 and 6. 



V. 

PERIPHERAL PALSIES FOLLOWING MANUAL RE- 
PLACEMENT OF THE CONGENITALLY DISLOCATED 
HIP. 

HENRY LING TAYLOR, M.D., NEW YORK. 

Among Professor Lorenz's most admirable qualities are his 
readiness to answer pertinent questions and his frankness in 
relating the difficulties and dangers incident to manual replace- 
ment of the congenitally dislocated femoral head. Perhaps 
the chief danger connected with this procedure is that its seem- 
ing fflmplicity in the hands of a master may cause those less 
experienced to underestimate the skill necessary to success 
and to ignore the complications to which it is liable. 

In observing the cases operated on by this method in several 
New York hospitals in the last few months, the writer has been 
struck with the slowness with which some of the patients learned 
to walk. On investigation it was found that the quadriceps 
muscle in several cases was completely paralyzed. With the 
patient seated and the leg hanging, there was no power to ex- 
tend the knee, while the knee flexors and foot muscles showed 
normal activity. The anterior crural nerve had evidently been 
injured by the manipulations. In applying the test, care should 
be taken to see that the patient does not first flex the knee 
and then allow it to swing forward by its momentum or from 
movements of the body. The quadriceps cannot be properly 
tested in the recumbent position, since the leg may be advanced 
by movements of the foot against a horizontal surface. In 
some cases passive extension was somewhat limited by con- 
traction of the hamstrings, but this did not interfere with ex- 
tension of the pendent leg. 

My attention having been called to this complication, cases 
were examined, by the courtesy of Professor Gibney, Professor 
Plimpton, and Professor Townsend, as occasion offered; and 

Presented at the Seventeenth Annual Moetinsr of the Association, Washinsrton. 
D.C., May 11-14. 1903. 



274 CONGENITAL DISLOCATION OF THE HIP. 

nine instances of quadriceps paralysis, one of peroneus palsy, 
and one of sciatic were discovered among the cases operated 
on in December or later. Of the quadriceps palsies three were 
double, making twelve limbs affected. 

The ages of the nine patients ranged from two years and a 
half to eleven years, but only four were over six years: all were 
girls. The compUcation was therefore frequent in this group 
of cases, and it occurred repeatedly in the hands of the most 
expert operators. The paralysis was in all cases complete 
when the cases were first examined a month or two after the 
operation, with the exception of one examined two months 
later, which was partial at that time. In all the cases but one, 
which has not recently been seen, the paralysis began to re- 
cover during the third or fourth month, and the recovery was 
either complete or was still progressing at the last examina- 
tion. The complication seems, therefore, not to be serious, 
and the prognosis is decidedly good, even without treatment, 
for none of the cases received any for the paralysis. It should, 
however, be recognized as a conmion cause of delayed walking 
after reposition. 

In addition to these cases of quadriceps paralysis I have 
observed two cases of foot-drop following the operation, without 
involvement of the quadriceps. In a girl of ten years of age 
there was a complete paralysis of the anterior 1^ muscles, with 
foot-drop, apparently due to stretching of the peroneal nerve: 
this patient is now recovering. In a thirteen-year-old girl all 
the muscles below the knee, both front and back, were para- 
lyzed; and three months after the operation there was evidence 
of but a faint trace of returning power. The palsy in this case 
was imdoubtedly due to a stretching or rupture of the sciatic 
above its bifurcation. These peroneal and sciatic palsies are 
more serious than the crural; and, if due to rupture of the 
nerve, they may be permanent. Both cases observed were con- 
siderably beyond the age and limit, and in one reposition was 
not accomplished. 

Professor Lorenz, in his monograph on the treatment of Con- 
genital Hip Dislocation, published in 1900, reports five cases 



H. L. TAYLOR. 



275 



No. 


Age. 


Side. 


^Dateof 
Operation. 


Examinatioii* 


Quadriceps 


Results. 








1902. 


1903. 






1 


6 


R 


Dec. 15 


Feb. 18 


Partial 




2 


6 


D 


Dec. 16 


Feb. 25 


Total both 


March 18, slight 
power left; April 
3, slight power, 
right; April 24, 
good power both. 


3 


10 


D 


Dec. 16 


March 18 


Total both 


April 22, slight 
power both. 


4 


5 


R 


Dec. 17 


Feb. 22 


Total 


May 7, still on 
crutches; can ex- 
tend knee. 


6 


8 


L 


Dec. 17 


Jan. 23 


Total 




6 


^ 


D 


Dec. 17 


March 30 


Total both 


May 7, can extend 
knees somewhat 


7 


11 


R 


Jan. 14 


Feb. 18 


Total 


May 7, complete 
recovery. 


8 


9 




Jan. 15 


Feb. 18 


Total 


May 7, recovery. 


9 


4 




Feb. 13 


March 28 


Total right 


April 18, slight 
power. 


10 


10 




Dec. 17 


Feb. 18 


Palsy pero- 
neus nerve; 
drop-foot 


April 30, nearly 
complete recov- 
ery. 


11 


13 


D 


Feb. 18 


March 10 


Complete 
palsy right 
sciatic; no 
power be- 
low knee 


May 8, very slight 
motion at ankle. 



of quadriceps and three of sciatic paralysis out of some four 
hundred replacements: all of the former recovered. My ob- 
servations agree in all respects with those above recorded, 
except that in the series here reported the paralysis is more 
frequent, having occurred in a group of less than fifty cases, 
and is by no means confined to the older cases. It should be 
remembered, however, that a quadriceps palsy might easily 
escape notice, and the child's difficulty in walking be attributed 
to the awkwardness of the posture. 

The conclusion is obvious from the frequency of this compli- 
cation and from the liability to more serious accidents that the 
manipulations should be deliberate and careful, and that, when 
serious obstacles to reposition exist, the attempt to reduce 
the dislocation by manual force alone should be abandoned. 



276 CONGENITAL DISLOCATION OF THE HIP. 

DISCUSSION. " " 

Dr. RoswELL Park, of Buffalo, was invited to open the discussion. 
He said he had listened to the papers with great interest, and had been 
impressed with the folly of calling this a ''bloodless" method. He 
believed that often more blood was shed and more harm was done than 
by the combination such as had been suggested by Dr. Bradford. He 
did not think it was safe to break bones and tear tissues so indiscrimi- 
nately as had been done in the employment of this method. 

Professor Tiffany, of Baltimore, was invited to speak. He said that 
he appreciated the honor very much, but had been unable to attend the 
meeting until near the close of Dr. Bradford's paper. 

Dr. James E. Moore, of Minneapolis, was also called upon. He 
said that he had only come into the meeting to learn, and had not ex- 
pected to speak, and yet he was glad to have the opportimity, because, 
with all honor to the method and to those who had brought it to a won- 
derful state of perfection, he felt that there were certain attendant dan- 
gers which had been briefly touched upon by Dr. Park. He had not 
had the pleasure of seeing Lorenz operate, although he had seen a good 
deal of him in connection with the meeting of the American Medical 
Association. From time immemorial it had been customary to reduce 
recent dislocations by mechanical manipulation, and wonderful skill 
had been developed along those Unes; but in all this time there had been 
some cases in which the surgeon had been unable to make a reduction. 
In pre-antiseptic days those cases were left imtreated; but, since we had 
learned that the tissues could be safely opened up, we had not hesitated 
to operate upon them and reduce these complicated dislocations. While 
it seemed perfectly rational that those skilled in the use of this method 
under discussion should resort to it, it also seemed rational to believe 
that there were a certain number of cases in which operative treatment 
would offer better chances to the patient. He thought the profession 
was liable to fly off at a tangent in this instance, as, unfortunately, in 
many others in times gone by, — unfortunately, one of our great weak- 
nesses. The method touched a chord of sympathy among the laity, 
for they disliked the idea of the shedding of blood; but, as Dr. Park 
had remarked, this operation often caused a much greater loss of blood 
than a clean-cutting operation in the hands of the expert surgeon. He 
was satisfied that finally, when the experience of all surgeons had reached 
perfection, there would still be some cases demanding a clean, open 
incision. 

Dr. V. P. GiBNET said that he had not as yet tabulated the cases oper- 
ated upon at the hospital, having waited for the five or six months to 



DISCUSSION. 277 

roll by. He quite agreed, however, with many of the remarks made to 
the effect that the operation was one fraught with a good deal of danger; 
and, while many of us believed that a child of four years with congenital 
dislocation of the hip offered an easy case for reduction, he must dissent 
somewhat even from this opinion. The whole subject had been well 
treated by Dr. Bradford. He hoped to be able to present some statis- 
tics when the papers were published. 

Dr. N. M. Shaffer said he had listened with a great deal of inter- 
est to all that had been said, and he wished to express his great appre- 
ciation of Lorenz's visit and his efforts in this country; for he felt that 
orthopedic surgery had been immensely benefited thereby. Dr. Ix>renz 
had operated at his clinic in New York; and in every case before oper- 
ating he had asked if we were all ready for operation, — in other words, 
he was prepared to operate if a cutting operation seemed indicated. 
Hence he was not always a bloodless surgeon. He did not regard the 
operation as a brutal one any more than osteoclasis; and he regretted 
very' much the inability of Lorenz to be here at this time and partici- 
pate in the discussion, as had been expected. He wished to express 
his great appreciation not only of Lorenz's visit, but of his high scien- 
tific attainments. 

Dr. GsoROB B. Packabd exhibited some X-ray pictures of the cases 
operated upon in Denver by Lorenz. Six cases were operated upon, 
and four returned later, and X-ray photographs were taken. In one of 
the other two the stability was very poor. In the other case, a child of 
nine years, the bloodless operation had been attempted; but, the skin 
and subcutaneous tissues tearing, the operation was abandoned, and 
the limb was put up in an abducted position. Two of the four skiagraphs 
showed the hip to be in perfect position: the other two skiagraphs showed 
anterior transpositions. 

Dr. J. RiDLON said he had seen a considerable amount of the work 
done by Lorenz in Chicago, and he wished to say that he was a thor- 
ough believer that this was .the best operation. He had notes, though 
not final ones, of 21 cases upon which Lorenz operated, and on 26 cases 
that he refused to operate upon, making 47 altogether. Of the cases 
operated upon, in 4 instances he failed to replace the hip, in 1 instance 
he fractured the neck of the femur, and in 1 instance the shaft of the 
femur, making 6 cases in which replacement was not obtained. In 
one of these cas^, but not in the case of fracture, paralysis of the sciatic 
group resulted, and had not yet entirely disappeared. In one instance 
in which replacement was effected, the perimeiun was torn. Dr. Ridlon 
said he had uncovered four hips upon which Lorenz had operated. The 



278 CONGENITAL DISLOCATION OF THE HIP. 

first was a child of four. The hip was found in anterior transposition, 
and the joint firm. In the next case, a bilateral one, one hip was either 
in the socket or very slightly in front of it; the other hip in that child 
was the one in which fracture of the neck of the femur occurred, and the 
head of the femur could be felt lying on a level with the greater trochanter, 
and to the posterior and upper side of it. This gave a total of 10 cases 
in which the final results were known out of the 21 operated upon by 
Lorems. All of the cases would be reported upon in detail at a later 
time. Of the cases not seen, but heard from, there were three. One 
was said to be in good position ; one was said to be an anterior position, 
with the head beneath tl^e femoral artery and nerve; in a third case 
Dr. T. A. Davis, of Chicago, reported that, when the plaster splint was 
removed, the head of the femur at once slipped out of the position in 
which Lorems had placed it, but was easily replaced in the same position. 

Dr. B. E. McKensie thought it was unfortunate that the laity, and 
too largely the profession, discussed this question as if Professor Lorenz 
had claimed to present a perfected operation. He agreed with those 
who said that Lorenz took no such stand, but presented his claims in 
a very unostentatious and modest manner. When asked, at the Hos- 
pital for Ruptured and Crippled, what results he thought he was obtain- 
ing, he replied that, when there was a double congenital dislocation, 
he thought a successful result should be obtained by him in 25 per cent., 
and, when there was only one hip affected, he should obtain a successful 
result in 50 per cent, of the cases. This seemed to be entirely at variance 
with what was believed in general by the laity and very largely by the 
profession. Lorens seemed to realize that he was encountering stiU 
very serious and unsolved problems. Some of the papers described 
Lorenz as a man of Herculean strength, and stated that he manifested 
this when operating upon his cases; but Dr. Wilson had called atten- 
tion to the fact that very frequently it had not been found necessary 
to make use of much force when one became experienced in the neces- 
sary numipulations. The speaker said he had seen Lorenz operate, 
and had not observed the use by him of any great amount of force. It 
was unfortunate, therefore, to allow these statements to go forth regard- 
ing the amoimt of force which Lorenz used. 

Dr. Artbitr J. Gillette said that orthopedic surgeons realized, but 
the laity and many of the medical profession did not, that congenital 
dislocation of the hip did not necessarily render the patient a hope- 
less cripple, if left alone. Many of these persons did well after a time, 
if untreated. This fact should not be forgotten. 



DISCUSSION. 279 

Dr. Leonard W. Ely, of New York, said he had listened with great 
interest to this discussion. The accidents, occurring as they did in the 
practice of men of known skill, showed conclusively that the operation 
was not one free from danger. The practical unanimity of opinion 
among orthopedic surgeons that this condition gave rise to much 
disability and that something should be done, was worthy of note, as 
also the fact that this operation seemed to be the best yet devised. 

Dr. Db Forest Willard, of Philadelphia, said he had performed 
the forcible reduction operation for several years before Lorenz's visit 
with indifferent results, but since then he had been using more force, 
and had succeeded better in reducing the dislocations. Both the clinical 
examination and the skiagraphs, however, had shown in every case 
not only a defective acetabuliun, but a distorted head and a malformed 
neck. He felt sure, therefore, that a considerable niunber of these cases 
would relapse within a year after the child began to walk. The term 
"bloodless" should not be applied to this operation, for a torn muscle 
bleeds far worse than does a clean incision with a tenotome. In the 
three of the last twelve cases he had divided the adductors. He thanked 
Dr. Bradford very much for the point with regard to the resistance of- 
fered by the adductor magnus, for previously he had been of the opinion 
that the resistance came from the adductor longus. With regard to 
the apparatus described by Bradford he would say that he could not 
believe that a mechanical device of this kind was as safe as the use of 
the hands. The perfected operation wiU consist of division of the mus- 
cles in addition to manipulative procedures. It was true that many per- 
sons with congenital dislocation grew up and became strong and vigor- 
ous, yet they suffered from lordosis and walked badly. He was inclined 
to think that, when a femur has been lying for ten or twelve years on 
the dorsum of the ilium, it would do more ,harm to transpose it into 
the anterior position than to leave it alone. At the present time he 
would be disinclined to throw the head forward in a case over eight years 
of age. 

Dr. A. J. Steele said that many of the cases operated upon by Lorenz 
had been imder his observation only for a few years. Dr. Dexter D. 
Ashley, who had been with Lorenz, told him that not infrequently Lorenz 
applied traction for a long time. Reference was made to the case of 
a strong child of seven years upon whom Lorenz had refused to operate. 
Subsequently by long traction and division of the adductors, and by the 
use of screw power before operation, it had been found possible to 
reduce both hips. 



280 CONGENITAL DLSLOCATION OF THE HIP. 

Dr. Dexter D. Ashley, of New York, was invited to speak. He 
said that he did not feel that he could speak for Lorenz, although he 
had listened with much pleasure to the discussion. He had 52 cases 
under his own observation, and hoped to be able to publish the results 
at some future time. 

Sir William Hingston said that the discussion to which he had lis- 
tened amply repaid him for the trouble of coming from near the north 
pole to this centre of American science. He had never listened to a 
discussion anywhere characterized by more fairness, clearness, and im- 
partiality, whatever the daily press might say to the contrary. Dr. 
Lorenz was not upon his trial: it was his method which was being sub- 
jected to scrutiny. The examination of the subject should certainly 
be impartial as regards the surgeon, but it was chiefly in the interests 
of the little patient. The dangers on the one side and the advantages 
on the other side should be carefully conindered by the slow process of 
analysis of cases, and later by synthesis and groupings. It is fortunate 
for the sufferers all over the world that Dr. Lorenz had come to America; 
for the subject had been and will be approached without prejudice and 
previously conceived notions, and in a short time no doubt the whole 
question will be presented for the consideration of surgeons generally. 

Dr. Starr spoke of the ligamentimi teres, which we had been inclined 
to think was absent in these cases, and called attention to a case in 
which that had proved an obstacle to reduction. 

Dr. Kurtz said there was still an obstruction not yet mentioned; t.e., 
the elongated capsule. It was occasionally a decided obstacle in the 
reduction. Lorenz overcame this by long-continued abduction and 
adduction. 

Dr. G. G. Davis, in closing, said that the object of his paper was to 
call attention to the fact that accidents had occurred. At the time 
he did not know that these other papers were to be presented, but they 
served to substantiate what he had said. He did not think enough 
stress had been laid upon the use of continuous traction, although Dr. 
Steele had alluded to it. His views regarding the operation not being 
bloodless had also been confirmed in the course of the discussion. LHti- 
mately, some of these cases would be treated by a cutting operation. 

Dr. H. A. Wii^ON said he felt that the very greatest and the highest 
tribute that would be paid to Lorenz and his visit to America was the 
fact that there would be very soon an entire disappearance of all cases 
of irreducible congenital dislocation of the hip beyond six or seven years 



DISCUSSION. 281 

of age. The result of his visit and the notoriety in the secular and med- 
ical press had been of much benefit in calling the attention of the general 
practitioner to these conditions; and, therefore, many of these cases 
would, in the future, be reduced at the time when this could be prop- 
erly done. 

Dr. E. H. Bradford said with regard to the obstacle offered by the 
ligamentum teres that he thought this had not been very thoroughly 
worked out. He had found the ligamentum teres present not infrequently 
in very young children with congenital dislocation, although it was usually 
absent in the older cases. With regard to the folding in of the capsule, 
he would say that some years ago he had shown a specimen in which 
this was present, and had then stated his belief that this was the chief 
obstacle to reduction. He was now inclined to think that he had ex- 
aggerated the frequency and importance of the obstacle thus presented 
to reduction. He hoped the members of this Association would discour- 
age the idea, apparently entertained by some members of the profession, 
that ever}' case having anything the matter with the hip was to be treated 
by forcible manipulation. The so-called Lorenz method was not a 
trifling procedure, even in a small child, and should only be undertaken 
when the diagnosis is certain. 



VI. 

A CASE OF SPASTIC PARALYSIS TREATED BY TRANS- 
POSITION OF HAMSTRING TENDONS. ALSO A 
CASE OF CONTRACTURE OF HAMSTRING MUS- 
CLES OF SPASTIC ORIGIN RELIEVED BY ELON- 
GATION OF HAMSTRING TENDONS. 

BERNARD BARTOW, M.D., BUFFALO, N.Y. 

The subject of the first cUnical report, a boy eleven years 
old, came under my care in June, 1902, for the treatment of 
congenital spastic diplegia. The history showed premature 
birth at the seventh month. Forceps delivery was employed 
to accelerate parturition, because the two preceding labors had 
been protracted and the infants were bom dead. The patient 
is the third oldest of eleven children, all but one other of whom 
were bom prematurely and lived but a short time, or were 
still-born at term. The parents are healthy, vigorous farming 
people. One sister, aged seven years, is living, and healthy. 

Spasticity was first noticed when the patient was about four 
months old, being general in distribution. Physical growth 
was much delayed until the fourth or fifth year. Mental de- 
velopment, sp)eech, etc., were backward, and enfeeblement of 
mind marked. Improvement in the foregoing conditions was 
not especially manifested until the sixth or seventh year. Spas- 
ticity was not associated at any time with athetosis. In the 
upper extremities and body the nmscle spasm diminished slowly 
after the seventh year. This was replaced by a moderate re- 
generation of muscular power, sufficient to enable the patient 
to sustain the sitting posture and to move about by dragging 
the body along the floor. The standing position could be sus- 
tained only by holding on to fixed objects, the malposture of 
the limbs and muscle spasm making it a very strenuous effort. 
(Fig. I.) The greatest amount of spasticity and contracture 

Presented at the Seventeenth Annual Meeting of the Association, Wasbingrton, 
D.C., May 11-14, 1903. 



B. BARTOW. 



283 



existed in the hamstring groups. These had become adapt ively 
shortened, so that the legs could not he extended to within 
forty-five degrees of the straight position. The flexors and ad- 
ductors of the thighs and the posterior leg groups contributed 




Fig. 1. Congrenital Spastic Diplegia (Little's Dis- 
ease). Appearance previous to transposition of the 
hamstriug tendons to quadriceps fenioris — June, 1902. 

to maintain the limbs in the characteristic flexed and crossed 
attitudes and equino-varus postures of the feet. (Fig. 1.) Ex- 
aggerated reflexes were present in all spastic groups. In the 
antagonistic groups there was diminished electrical reaction, 
being especially weak in the quadriceps. The quadriceps also 



284 SPASTIC PARALYSIS. 

evinced no contraction during the attempt to perform exten- 
sion of the legs. The palsied condition of these muscles seemed 
in large degree the effect of their long-continued maintenance 
in a stretched and disused state, from the spasm and contract- 
ure in the hamstrings. The general palsy and spasticity was 
regarded as belonging to the type distinguished clinically as 
Little's disease, and depending on uncompleted development 
associated with premature birth. Trauma from instrumental 
delivery probably contributed in no important degree to the 
nervous disorder. The labor was not prolonged, and the small 
size of the child undoubtedly made its extraction easy of ac- 
complishment. 

Operative indications in this case pointed chiefly to the relief 
of spasticity and contracture in the leg flexors. Relief of ten- 
sion in these groups was expected also to modify spasm in other 
groups, which had not undergone contracture. Simple elonga- 
tion of the hamstrings was deemed inadvisable, on account of 
the lowered muscular tone in the quadriceps. As the chief dis- 
turbing influence in performing locomotion existed in the ham- 
string groups, it seemed appropriate, when releasing them from 
their constrained relations, to place them in positions to lie 
of greatest value for the purposes of locomotion; namely, by 
attaching them to the weakened extensors. This seemed es- 
pecially indicated in view of their well-developed, vigorous con- 
dition. Dependence could be placed on the gastrocnemii for 
supplying flexion power such as would meet the requirements 
of function under these circumstances. 

With this plan in view, the semitendinosus, semimembra- 
nosus, and gracilis were separated .at their tendinous insertions 
to as full an extent as possible. The three tendons were inter- 
woven into one cord, and passed upward and forward through 
a tunnel under the fascia lata, and through buttonholes in the 
expansion of the vastus internus, and anchored to its aponeu- 
rosis, as near the patellar tendon as possible. The t-endon of 
the biceps was similarly detached and fastened to the apo- 
neurosis of the vastus extemus. After a protective had been 
applied over the operation field, the limb was encased in a 



B. BARTOW. 



285 



plaster-of-Paris splint from ankle to groin, to maintain it in 
the straight position. 
The operation on the second limb was made two weeks later, 




Flos. 2. 3. Same patient, twelve weeks 
after transposition of hanistringrs to quadri- 
ceps, showing correction of deformity in knees 
and relief of spasticity in associated muscle 
grroups. 

and was similar to the first in all its details. Releasing the ham- 
strings from their tense relations to the legs was quickly fol- 



286 



SPASTIC PARALYSIS. 



lowed by relief of spasticity in the thigh flexors, adductors, and 
leg groups. All malposture in the lower limbs was therefore 
relieved by operating on the hamstring groups only. (Figs. 2, 3.) 




Fig. 3. (See Fig. 2.) 

Following the operation, no movement at the knees w^as al- 
lowed for eight weeks. The splints were then removed, and 
the patient permitted to sit up. Massage and faradism of the 
thigh and leg muscles w^as employed daily, and the patient en- 
couraged to practise flexion and extension movements. He 



B. BARTOW. I 287 

was also assisted into the standing position, supporting his 
weight on the limbs for short periods frequently during the 
day. Advantage was taken of any fixed object conveniently 
situated, to support himself for a time in the standing position. 
At the end of ten weeks from the second operation, he was able 
to stand, lightly supported by the hands of a nurse. (Figs. 2, 3.) 
Four weeks later he could walk the circumference of the hos- 
pital ward, holding on to beds, etc. Evidence of increasing 
power to extend the legs was apparent from time to time. At 
the end of 'four months, when he left the hospital, extension of 
about fifteen degrees could be definitely, though feebly, ex- 
ecuted. The gastrocnemius supplied all the demands of a flexor 
muscle. 

The patient was not again seen by the writer for six months. 
At that time (April, 1903) his condition as regards locomotion 
and general vigor indicated continuous improvement during 
that interval. He was able to stand easily by steadying him- 
self with a cane or crutch. With the aid of crutches he could 
walk three-fourths of a mile. (Fig. 4.) The increase of power 
in the quadriceps was very marked, the patient while sitting 
being able to extend the legs to about sixty degrees. (Fig. 5.) 
Extension could not be made separately in each leg, when sit- 
ting, the associated action of the muscles of the other limb 
seemingly being the chief obstacle. The extension of the legs 
during locomotion is still feeble, and accompanied by a swing- 
ing movement of the limb; but there is the suggestion of steady 
improvement of muscular control. 

Not the least interesting feature of this case has been the 
rapid improvement of the patient's mental faculties. This 
began to be apparent shortly after the division of the spastic 
muscles, manifesting itself first by marked decrease of the ner- 
vous excitability that had been a constant accompaniment of 
the spasticity. 

This form of relief is often experienced following division of 
spastic and contractured muscles, and especially when these 
are flexor muscles. It suggests that the central excitement is, 
in part, a reflex of the continued muscle spjism. In those cases 



288 SPASTIC PARALYSIS. 

which present less promising features, where only temporary 
relief of spasm would be expected from tendon division, it 
would appear that more prolonged benefit might be obtained 




FifJ. 4. Same patient, nine months after operation. With the aid 
of crutches the patient could walk three-fourths of a mile. 

by transposition of spastic flexors than by division for elonga- 
tion purposes only. The opportunity aff'orded for associates! 



B. BARTOW. 289 

spasticity during attempted evolutions would not produce as 
much malposture if the legs were in this manner maintained 
in a position of better extension. 
Mental development in this patient became especially active 




Fig. 6. Same patient, showing the extension i>ower developed in the quad- 
riceps, nine months after operation, 

in connection with his efforts to perform locomotion. Even 
the facial expression, which indicated the feebleness of mind, 
soon changed to one of fair intelligence. (Figs. 3, 4, 5.) In con- 
versation the patient now expresses himself well on matters 
within the range of his educational opportunities. It is fair 
to assume that the limits of improvement have not yet been 
reached in this patient. The grow^th of body and mind and 



290 SPASTIC PARALYSIS. 

increase of functional vigor incident to performing even the 
present limited locomotion are factors on which expectation 
of further development and control may be built. 

In interesting contrast with this case is another of the same 
type, to which I will briefly allude. The main interest attaches 
to the different rate of development and the mode of treatment 
which was adopted. The patient, a boy fifteen years old, was 
bom at term, an undeveloped child, weighing a little leas than 
four pounds. Rigidity of the limbs was observed between 
three and four months after birth, and soon developed the char- 
acteristics of spastic diplegia. Muscle rigidities, which were 
especially marked as late as the sixth or seventh year, gradually 
diminished after that age, and were succeeded by nuiscular 
development of good quality. (Fig. 6.) The lower extremities 
retained spasticity in greater degree and for a longer period 
than the arms and body. But, even in the lower limbs, this 
gradually gave way to control, incident to growth and devel- 
opment, leaving only traces of the earlier spastic action and 
shortening in those muscles which had been affected in the 
highest degree. Flexors and extensors were well balanced; 
and, barring moderate spastic action and contracture of the 
hamstring groups, there was but slight noticeable defect. The 
shortened condition of the hamstring muscles maintained a 
bent-knee posture of twenty degrees (Fig. 6), which caused 
awkwardness of gait and fatigue from only moderate efforts 
in standing and walking. Incidental to the efforts of loconno- 
tion, spasticity was excited in muscles ordinarily free from it, 
when the patient became fatigued. The shortening in the 
hamstring muscles was structural and adaptive, due to the 
long-maintained spastic attitudes during the earlier years of 
the disturbance. Relief in slight degree had been afforded by 
tenotomy of the Achilles tendons, performed at the age of six 
jTars; but no other tendons were divided. For the improve- 
ment of locomotion, etc., the muscular conditions suggested 
only elongation of the hamstring tendons. This was done by 
the open method, within the tendon sheaths, in the following 
manner : — 



B. BARTOW. 



291 



The tendinous bands which converge as they are about to 
leave the body of the muscle, to form the tendon proper, were 
divided near the muscle, in the direction of its circumference. 
In the biceps and semimembranosus, after doing this, a core of 





Fio. 6. Residual ham- 
gtring contracture, from 
Little's Disease. Patient 
15 years of agre. 



Fig. 7. Residual ham- 
string contracture, from 
Little's Disease. Relieved 
by elongation of hamstring 
tendons. Appearance five 
months after operation. 



muscular fibres remains, continuing for some distance into the 
tendons, some of the fibres of the short head of the biceps reach- 
ing even to the insertion of the tendon. These muscular fibres 
preserve the continuity of the muscle with its tendon insertion 



I 

I 
292 SP.\STIC PARALYSIS. i 

after division of the tendinous bands, so that complete separa- 
tion does not occur while repair is taking place. This permits 
of limited but accurate elongation of the tendons, and, in addi- 
tion, these muscular fibres may te stretched without causing 
them to separate from the tendon if the division of the tendi- 
nous portion does not give sufficient length. The seraitendi- 
nosus tendon was elongated by splitting. The iliotibial band 
was also very resistant and short, and required free division. 
Elongation in this manner gave perfect functional action of 
the flexors as soon as repair was well established. Improve- 
ment in posture and gait was quickly manifested, and the signs 
of previous spasticity have since diminished in a large measure. 
A comparison of the posture before operation (Fig. 6) with that 
shown in Fig. 7, about three months afterward, quite accurately 
illustrates this feature of the improvement. 



VII. 

SLIPPING OR RECURRENT DISLOCATION OF THE PA- 
TELLA: WITH THE REPORT OF ELEVEN CASES. 

JOEL E. GOLDTHWAIT, M.D., BOSTON, MASS. 

The above condition is seen almost entirely in girls or women, 
and is due, in large part, to the fact that the line of pull of the 
quadriceps extensor muscle is not straight, this feature being 
increased in its effect by an unnaturally long patella tendon, 
knock-knee, or an imperfectly developed articular surface at 
the end of the femur. Eleven cases of this condition, seven 
operative with thirteen operations and four non-operative, 
have been seen and treated by the writer; and the observations 
made in connection with the treatment of these cases represents 
the basis of this paper. 

The first feature, or the indirect muscle pull, is in part noraial 
anatomically. The tubercle of the tibia with the attachment 
of the patella tendon is distinctly to the outside of the central 
portion of the patella, when the knee is extended and the muscles 
are at rest. As the action of the muscles together with the 
joint motion is studied, it is seen that during flexion the patella is 
drawn forward over the articular surface between the condyles 
of the femur, and inclines slightly, but distinctly, to the outside 
of the median line. As extension takes place, the patella 
ascends, incUning slightly toward the inner side until, when 
extension is complete, the line formed by the origin of the rectus 
femoris, the centre of the patella, and the tubercle of the tibia 
makes an obtuse angle. As the muscle contracts, the natural 
tendency is to straighten this line, with the necessary result 
that the patella is drawn outward, representing, as it does, 
the only movable point in the line. This can easily be demon- 
strated in any normal joint, if the knee be fully extended and 
the quadriceps muscle be alternately contracted and relaxed. 



294 



RECURRENT DISLOCATION OF THE PATELLA. 



The lateral movement of the patella is distmct, the limit out- 
wardly being controlled in part by the ligaments, but more 
particularly by the outer ridge of the trochlea surface of the 
femur, which is distinctly higher in its upper and anterior sur- 







Fio. 1. ((Jray) 



face than the same ridge at the inner side. Against this the 
patella impinges, and displacement further is impossible, as 
long as all the parts are normal. 

If for any reason the line of pull becomes less direct or the 
articular ridge less perfectly formed; if the capsule be weakened 
by the distension following some acute injury; if the patella 



J. E. GOLDTHWAIT. 295 

tendon be abnormally long, so that the patella is drawn above 
the outer edge of the trochlea surface of the femur, or if the 
joint can be hyperextended so that during the muscular pull 
the patella is lifted away from the femur, — in either of these 
conditions the stability of the joint, so far as the patella is con- 
cerned, must be materially lessened. 

The displacement of the patella which results from such a 
mechanical condition may occur frequently with sim[)le motion 
or muscular contraction, or may develop only when attended 




Fig. 2. (Gray) 

with the application of considerable force and when combined 
with some lateral strain, the ease or difficulty of the displace- 
ment depending, of course, upon the degree to which the normal 
condition has been modified. In the extreme conditions the 
displacement may become permanent, in which case the inner 
portion of the capsule becomes permanently stretched, while 
the outer portion shortens. In this condition the patella rests 
upon the outer surface of the outer condyle of the femur; and 
complete extension, which depends upon the pull of the quad- 
riceps extensor, acting through the patella over the lower and 
anterior surface of the femur, is impossible. If this extreme 
or permanent condition occur in childhood or before the bone 
growth is complete, the condyles of the femur conform in their 



296 RECURRENT DISLOCATION OF THE PATELLA. 

development to the range of motion, so that ultimately com- 
plete extension of the joint is impossible, the limitation not 
being due to Hgamentous or tendinous contracture, but to a 
change in the articular planes. These extreme features were 
present in Case 1. 

It is also true that, if the displacement persist for any length 
of time in the growing child, a twist in the upper end of the 
tibia results, so that, even though the patella be replaced, the 
angle in the pull of the muscle is so much increased that dis- 
placement occurs as soon as the muscle contracts. 

From my observations in this limited number of cases it 
seems to be true that, if the patella has slipped out several times 
without special violence, it is an evidence of joint instability, 
due to one of the above-mentioned conditions; and, while the 
slipping may be controlled by simple measures, the weakness 
usually remains, and the joint is unable to stand the strain of 
normal use. For this reason, although bandaging, braces for 
the knees, the correction of flat or pronated feet, should always 
be tried in the early stages of the trouble before the slipping 
has become frequent, comparatively little is to be expected in 
the way of permanency of relief from such measures if the 
slipping has recurred several times, unless the patient be very 
young. 

The chief point in the treatment naturally consists in the 
correction of the angle in the line of muscle pull, so far as it is 
possible. If knock-knee be present, the lateral motion of the 
patella during use will naturally be increased. If the knock- 
knee is due simply to the loose internal lateral ligaments, it is 
conceivable that by thoroughly correcting this the lateral move- 
ment of the patella may be lessened and the slipping or dislo- 
cation cease. I have not been able to accomplish this in any 
of the cases here reported, although one seemed favorable 
as to age, but to expect improvement is reasonable from the 
study of the mechanics, if the cases can be seen before bone or 
other permanent changes have taken place. 

If marked knock-knee with the usual bone changes be present, 
this should of course be corrected; but, as this feature was pres- 



J. E. GOLDTHWAIT. 297 

ent in but one of the cases under discussion, it is probably not 
as common as has been supposed. 

If the patella tendon be long, so that in complete extension 
the patella is drawn above the outer ridge on the trochlea sur- 
face of the femur, it should naturally Ix? shortened, as, unless 
the normal mechanical relations can be restored, the joint must 
be unstable. To correct this, the tendon should be shortened; 
and in doing this it is better, as it lessens the danger of relapse, 
at the same time to change the attachment of a portion of the 
tendon, thus making the line of pull more nearly straight. In 
the one c^ise in which the tendon was simply shortened, relapse 
occurred, entire relief following the second operation, in which 
the other half of the tendon was transplanted. 

If, after studying the mechanics of the given joint carefully, 
the relaxed inner half of the capsule is the only defect, this 
should naturally be tightened. It is my impression, however, 
that this is almost never the case, and that the relaxed capsule 
is a result of an abnonnal condition rather than the cause, 
and that, if the cause be corrected, the relaxation of the cap- 
sule will take care of itself. In the three operations performed 
by me, in which only the inner portion of the capsule was tight- 
ened, all relapsed; while in the cases which have been operated 
on since, and the patella tendon reattached, the capsular relax- 
ation has entirely disappeared, although at the time of the 
operation the capsule itself was entirely ignored. 

In the majority of the cases, when carefully studied, it will 
be seen that the attachment of the patella tendon is distinctly 
farther to the outside than normal, making less direct the pull 
of the anterior thigh muscles; and with this the ridge on the 
outer edge of the articular surface of the femur is less marked 
than normal. 

The treatment which has been most satisfactory in meeting 
this condition is an operation hi which the outer half of the pa- 
tella tetndon is reattached to the tibia well to the inside of the 
tubercle. In this way the angle in the nmscle pull is lessened 
or entirely removed, so that the patella is drawn firmly across 
the articular end of the femur and the presence of the ridge at 



298 RECURRENT DISLOCATIOX OF THE PATELLA. 

the outer side is made of less importance. Of the eight opera- 
tions which have been performed in which this has been the 
chief feature, in seven no after-trouble has resulted, and the 
stability of the joints has made them equal to normal use. 
In one in which the tendon had at the same time been shortened, 
the first attachment did not remain firm, so that a second oper- 
ation was necessary. 

The operation as carried out at present consists of a longi- 
tudinal incision four or five inches long, extending from just 
below the tubercle of the tibia upwards. Through this the pa- 
tella tendon is exposed and split in halves, antero-posteriorly, 
throughout its entire length. The outer half is then cut from 
its attachment, passed under the remaining portion, and at- 
tached to the periosteum, together with the expansion of the 
tendon of the sartorius muscle at the inner side of the anterior 
surface of the tibia. If it is desirable to shorten the patella 
tendon, the attachment can be so made that the patella is 
drawn down as much as is desirable: but, as this means much 
tension upon the new attachment, a hole should be drilled in 
the bone at the point of attachment through which the suture 
is passed which holds the tendon. The carrying of the free 
portion under the other is of importance, as in this way the 
patella is tilted, the outer portion being drawn downwards, 
and impinges more firmly against the outer ridge of the articular 
surface of the femur during muscular contraction, so that the 
danger of displacement is materially lessened. 

The attachment is made with strong silk, quilted through the 
tendon. The wound should be tightly closed, and the leg fixed 
in a plaster of Paris bandage from the ankle to the groin, the 
contraction of the quadriceps extensor being eliminated as much 
as possible by applying a tight gauze bandage from the knee 
to the groin under the plaster. The fixation should be kept 
up for about six weeks. 

In performing the operation, the inner half of the tendon or 
that most favorably situated for the direct muscular pull is 
entirely undisturbed, so that, in case the transplanted portion 
fails to imite, function is still possible, and some improvement 



J. E. GOLDTHWAIT. 



299 



must still result, as the simple removal of the outer half of 
the tendon practically moves the existing attachment of 
the tendon that much farther to the inside. 




Fig. 3. 



In perfecting the operation, various measures have been 
tried. The inner half of the tendon in one case was transplanted, 
with ultimate relapse. The entire tendon was transplanted 
in one case with a perfect result; but this was not repeated, 
as the later operation possessed less danger from possible fail- 



300 RECURRENT DISLOCATION OF THE PATELLA. 

ure of the new attachment to hold. In one case the patella 
tendon was simply shortened with subsequent relapse ; and in one 
case the entire tubercle of the tibia was transplanted and 
nailed to the inner side of the tibia with a good functional result, 
but with a nmch longer convalescence than is required in tlie 
operation described in detail above. The cases in which simply 
the inner portion of the capsule was shortened all relapsed. 

The cases are reported in detail below. In the operated cases, 
with possibly one exception, a sufficient length of time has 
elapsed for a thorough test of the joint to have been given. 

Case 1.— This case has been previously reported (Annals 
of Surgery, January, 1899), and represents a case of dislocation 
of both patella? in which the malposition had become perma- 
nent. The patient was a woman thirty years of age, and was 
first seen in February, 1895. The trouble with the knee began 
without injury at t-en years of age. Treatment was sought 
because of pain in the back, which resulted from the peculiar 
attitude in standing. 

On examination both patellar were on the outer surface of 
the outer femoral condyles, and replacement was impossible. 
The tibia was rotated outward considerably, so that the attach- 
ment of the patella tendon was much farther to the outside 
than normal, and complete extension of the knee was impossible, 
due apparently to the abnormal development of the articular 
surfaces of the lower end of the femur. On standing, the knees 
were flexed and braced against each other, increasing consider- 
ably the normal lumbar curve, with resulting muscle strain 
and backache. There was slight knock-knee; and the gait on 
walking was awkward, one leg being throwTi aroimd the other. 
Horizontal extension of the legs was impossible. 

The con*ection of the position of the patella? by any manipu- 
lation was impossible, so that the patient entered the Carney 
Hospital, and in March, 1895, the right knee was operated upon 
as follows: — 

Through an 8-inch incision, beginning above the knee on the 
outside and extending downward across the knee to the inside, 
the capsule of the johit was exposed. Even with the skin re- 
moved, the patella could not be brought up into its normal 
position, and a longitudinal incision three inches long was made 
through the outer part of the capsule. After this the disloca- 
tion could be corrected without difficulty; but, because of the 



J. E. GOLDTHWAIT. 301 

change which had taken place m the shape of the ends of the 
bones, the tubercle of the tibia was so much farther to the out- 
side than normal that, when the joint was flexed, the patella 
slipped out of place again. In order to obviate this and to 
have the attachment of the patella tendon m the proper place, 
the tendon was cut off and sewed to the periosteum and the 
expanded tendon of the sartorius on the inner and anterior sur- 
face of the tibia. The loose capsule on the inner side of the 
joint was next shortened with quilted sutures; and, for fear 
that the strong thigh muscles should tear away the new attach- 
ment before it should become firm, about three-fourths of the 
quadriceps extensor was divided just above the patella. The 
wound was then tightly closed, the skin being depended upon 
to close the gap (three-quarters of an inch broad) in the outer 
part of the joint capsule, made necessary to draw the patella 
foi-ward. 

The recovery was uneventful. There was very little pain, 
and practically no elevation of temperature. The wound was 
healed in one week; and motions, which were not in the least 
restricted, were allowed at the end of one month. A leather 
knee splint, to prevent any sudden violence and the possible 
tearing away of the newly attached tendon, was w^orn during 
a part of the time for a few months. 

As soon as the patient was able to be about, even though one 
patella was in place and the action of the knee improved, the 
difficulty in completely extending the knee remahied, so that 
the lordosis was not lessened. To correct this, an osteotomy 
of the femur above the condjdes was performed in both legs 
and the knees straightened. The convalescence from this 
operation was uneventful, and eight weeks from the time of its 
performance the left knee was operated upon to correct the posi- 
tion of the patella. The operation was similar to that which 
was used in the other joint, except that, instead of cutting off 
the patella tendon and reattaching it, the whole tubercle of 
the tibia was chiselled off, and nailed to a depression which was 
made on the inner side of the bone. The reason for this change 
in the procedure was that, while the other knee had shown no 
signs of weakness, nevertheless it was my feeling that a bony 
attachment would probably be more secure. With this, of 
course, it was not necessary to cut away so much of the attach- 
ment of the quadriceps extensor above the patella. 

Instead of the primary union, as was obtained in the other 
knee, the tendon and the piece of transplanted bone sloughed 
considerably, so that, instead of healing in one week, about three 



302 RECl'RRENT DLSLOCATION OF THE PATELLA. 

months were necessary before the wound was entirely closed. 
During much of this period the patient was able to be about, 
but the healing was not complete until then. The functional 
result in this joint is also not as good as in the right; and, while 
complete extension is p)ossible, there is only about 90 per c-ent. 
of motion in flexion. 

Since the operation there has never been the slightest indi- 
cation of the old pain in the back, the lordosis has been cor- 
rected, the gait Ls much improved, and, except for the limita- 
tion in flexion in the left knee, the patient is perfectly well, 
with the normal function of the joints. On walking or stand- 
ing, the inward rotation of the legs has disappeared; and, on 
sitting, complete extension of the leg is easily performed en- 
tirely without the twist of the leg that developed with the at- 
tempt at such movement before the operation. It is now seven 
years since the last operation was performed ; and during much 
of that time the patient has been at work in a factorj'', able in 
every way to meet the demands made upon her. 

Case 2. — Miss M. L. O'B., thirty years of age, was seen, in 
consultation with Dr. Charles Putnam, in April, 1887. 

Since childhood both knees had slipped on slight provoca- 
tion, the condition having come on without injury or other 
known cause. The slipping caused great inconvenience, pro- 
ducing frequent falls, and being followed commonly by joint 
swelling. 

Bandages, massage, and appliances had been thoroughly 
tried, and failed. Accordingly, both knees were operated upon; 
and the inner portion of the capsule of the joint was shortened, 
so that, when the wound was closed, it was impossible to slip 
the patella out of the trochlea groove. At the time of this oper- 
ation the importance of attachment of the patella tendon in its 
relation to the line of pull was not appreciated by me; and, as 
there was no literature upon the subject, this feature was en- 
tirely ignored. 

After the operation the wounds were tightly closed, and the 
period of healing was uneventful. Very soon, however, after 
the patient began to go about, the capsule stretched again, so 
that the dislocation recurred, there being no permanent improve- 
ment from the operation. 

Further operation was refused by the patient. 

Case 3. — Mary F., seventeen years of age, was seen May 29, 
1897, because of slipping of the left patella, which had begun 
five or six years before without known injurj^, and had slipped 
at infrequent intervals ever since. 



J. E. GOLDTHWAIT. 303 

At the time of the first examination the chief feature to attract 
attention was the abnormal length of the patella tendon. The 
attachment of the tendon in this instance was not noted, and 
the first operation consisted of shortening the tendon about 
three-fourths of an inch and quilting the inner side of the cap- 
sule of the joint. 

The healing after this operation was uneventful, and the imme- 
diate effect was satisfactpry; but later on, however, the slipping 
or dislocation reciured, and became as troublesome as before. 

As the essential principle of the treatment had been by this 
time recognized, a second operation was performed Jan. 18, 1901 ; 
and the outer half of the tendon was cut away, passed under 
the undivided portion, and attached well to the inside of the 
tibial tubercle, as has been described above. 

The recovery was uneventful, and no further trouble has 
resulted. The knee is used freely, and is apparently perfectly 
strong. 

Case 4. — ^E. R., a girl of seventeen years of age, came under 
treatment five years ago for trouble with the left knee, which 
had existed since childhood. Under the simplest movement 
the patella slipped to the outside, unless controlled by a band- 
age. There had been no definite injury or known cause for 
the trouble. Tlie examination showed a strong, well-formed 
girl with the left knee much relaxed and the patella abnormally 
moveable, so that displacement to the outside was easily pro- 
duced. The feet were quite flat, but there was no knock-knee, 
and the patella tendon was not unusually long. The a^ttach- 
ment of the patella tendon was farther to the outside than nor- 
mal, so that with every contraction of the quadriceps extensor 
muscle the patella was displaced laterally an abnormal amount. 

On April 27, 1899, the patient was operated upon, and the 
inner half of the patella tendon was cut away and reattached 
to the periosteum on the inner side of the tibia. At the same 
time the capsule at the inner side of the joint was tightened 
by quilted sutures. 

The recovery was uneventful; but a few months later the 
sjrmptoms recurred, and have persisted ever since. The pa- 
tient is now awaiting further operation in which the outer por- 
tion of the tendon is to be transplanted, thus correcting entirely 
the obliquity of the muscular pull. 

In this case, had the inner half been left undisturbed and the 
outer portion given the new attachment, as has been the case 
with the later operations, the necessity of the second operation 
would probably have been avoided. .^..^ 



304 RECURRENT DISLOCATION OF THE PATELLA. 

Case 5. — M. C, a young woman seventeen years of age, came 
for treatment in April, 1899, complaining of trouble with both 
knees. When nine years of age, she was thrown down and one 
patella slipped out. Soon after this the other slipped, and 
ever since at intervals varying from a few weeks to a year the 
slipping has been repeated, sometimes one and sometimes the 
other giving out. After each slipping the joint has swelled, 
necessitating quiet and bandaging for a few weeks. The slip- 
ping occurred sometimes with violent use and sometimes upon 
slight movement. 

The examination showed a strong, well-formed girl, the only 
apparent defect being the relaxation and weakness of both 
knees. The patellse could easily be displaced laterally; and 
their lateral movement to the outside, during the contraction 
of the quadriceps muscle, was quite noticeable. There was 
no knock-knee, and but slight pronation of the feet. 

Previous to consulting me, the patient had had for over a 
year systematic massage with some mechanical treatment, 
without improvement, so that after first correcting the prona- 
tion of the feet, still without improvement, an operation was 
performed, in which the outer half of the patella tendon was 
transplanted to the inner side of the tibia, as has been described 
above. Both knees were operated upon at the same time. 
The recovery was imeventfid. At the end of four weeks the 
plaster bandages were removed, and movement allowed in bed. 
Two weeks later the patient was allowed up, the only protec- 
tion being a light flannel bandage which was worn during the 
daytime for a few months. 

As to the ultimate result, in the four years which have elapsed 
since the operation, the patient has been active in sports and 
games, with absolutely no weakness or symptoms referable 
to the knees, except that once in a romp she was thrown, wrench- 
ing one knee, causing a few dajrs of discomfort. Even in this 
violence the stability of the joint was not disturbed. 

It is an interesting fact that in this case, while the capsule 
had been much relaxed, and even though no attempt was made 
to tighten it at the time of the operation, the normal tonicity 
of the structures returned, with the restoration of the normal 
mechanical fimction and the relief of the lateral strain. 

Case 6. — M. C, a young woman twenty-three years of age, 
was seen in 1895, and treated for marked flat foot. For sev^al 
years before this the knees had been quite troublesome, shpping 
occasionally, sometimes one knee and sometimes the other. 
No definite cause could be assigned for the trouble. 



J. E. GOLDTHWAIT. 306 

The examination showed a strong, well-developed woman, 
with quite marked fiat foot and with relaxed knee joints, but 
with no knock-knee. The movement of the patella to the out- 
side during the contraction of the anterior thigh muscles was 
quite apparent. 

Because of the definite character of the flat foot, it was thought 
wise to correct this first, hoping that by lessening the strain 
upon the knees the weakness and slipping might be modified. 

This, however, did not result, but instead the weakness and 
slipping became more marked, so that, while at first consider- 
able violence was necessary in order to develop the trouble, 
gradually the displacement became more and more easy, until 
it was apt to follow any slight simple movement, naturally 
causing great limitation of activities. 

In May, 1901, an operation was performed, and the outer 
half of the patella tendon was transplanted. Both knees were 
operated upon at the same time, and after six weeks in bed 
regular use began. Since then the patient has lived a thor- 
oughly active life without the slightest evidence of weakness. 

Case 7. — C. G., a young girl seventeen years of age, was seen 
in June last at the Vincent Hospital in consultation with Dr. 
Mary P. Hurd. 

The history was that eight months before the left knee was 
sprained, at which time the patella was probably dislocated. 
Without special violence the patella distinctly slipped out two 
months ago, and since that time it has slipped frequently and 
with but slight movement. On even turning over in bed, the 
dislocation often occiured. 

The girl was of good height and of fairly good physical devel- 
opment. The left knee was much relaxed, with but little in- 
crease in the synovial fluid; and the lateral movement of the 
patella was so free that with but very little force it could be 
entirely displaced. 

The patella tendon was fully a half-inch longer than normal, 
and the articular ridge on the outer edge of the trochlea surface 
of the femiu- was much less distinct than usual. The angle 
in the line of pull of the quadriceps extensor muscle was quite 
distinct. There was slight knock-knee, and the pronation of 
the feet was marked. 

For treatment the pronation of the feet was corrected and 
the knee strapped with adhesive plaster, and over this a flannel 
bandage applied; but in spite of this the slipping continued, 
and, as only when the knee was fixed in a plaster of Paris ban- 
dage was the slipping controlled, an operation was advised. 



306 RECURRENT DISLOCATION OF THE PATELLA. 

In the early part of July the outer half of the patella tendon 
was attached to the inner side of the tibia, the only difiFerence 
from the operation performed in the last two cases being that, 
as the patella tendon was too long, a lower attachment was 
made, and the patella drawn down to its normal position. 

The undivided portion was not shortened, as it was considered 
that this would take place unaided with the reUef of the strain, 
as is seen in other analogous conditions. 

The result from this operation was disappointmg. When 
use was first allowed, there was no trouble; but very soon the 
slipping recurred, due apparently to the failure of the new at- 
tachment to hold. The slipping was naturally less marked 
than in the beginning, owing to the removal of the outer half of 
the tendon; but it was sufficient to cause considerable insecurity 
in use. To overcome this, a second operation was performed 
^and the tendon reattached, the suture being passed through 
a hole which was drilled in the hone at the point of attachment. 
The knock-knee, even though not marked, was also corrected 
by osteotomy. 

The end result in this case cannot be stated; but, as the faulty 
mechanical features have been corrected, it seems reasonable 
to expect a stable joint. 

Case 8. — N. M., a yoimg woman twenty-three years of age, 
was first seen in April, 1899. The patella in the right knee ha^, 
without known cause, slipped out ten years before; and three 
times sinc« the slipping had been repeated. 

Simple conservative measures were advised, and the patient 
lost sight of until a few months ago, when she reported in re- 
sponse to a note. In the interval the weakness of the knee 
with slipping had become more frequent, and the left knee had 
also given out. In both the capsule is much relaxed, and 
the displacement of the patella is so easily produced tha]b there 
was much apprehension on the part of the patient during the 
examination lest this should happen. The angle in the line of 
muscular pull was quite noticeable. 

For further treatment an operation was advised in both knees, 
but as yet it has not been performed. 

Case 9. — ^Mrs. W. R. F., twenty-seven years of age, was seen 
first in May of 1902. The patella of the right knee had dis- 
located when she was eleven years old, and this had been re- 
peated about once a year for five years. After this there had 
been no actual slipping imtil one week before the first visit. 
In the interval of eleven years the patient had always been 
carefid of the knee, and most of the time had worn an elastic 
knee-cap. 



J. E. GOLDTHWAIT. 307 

The examination showed an otherwise healthy person, with 
the capsule of the right knee joint considerably relaxed. The 
lateral movement of the patella was abnormally free, and the 
displacement to the outside during the contraction of the quad- 
riceps extensor muscle was more than normal. 

Tliere was no knock-knee, but well-marked flat foot. 

For immediate treatment the knee was strapped with adhe- 
sive plaster, the flat foot corrected, and an operation advised 
to permanently correct the trouble. As yet this has not been 
performed. 

Case 10. — ^F. M., a yoimg and rapidly growing girl of seven- 
teen years of age, was seen in September, 1900, because of the 
slipping of the patella in one knee, which had but just devel- 
op^. 

The girl was growing rapidly, and all of the structures lacked 
tone. The knees were relaxed, and the feet also, so that there 
was marked pronation. This feature was corrected, the knee 
bandaged, and a course of general tonic treatment with exer- 
cise advised. 

For a time there was marked improvement following the treat- 
ment; but of late the slipping has recurred frequently, so that 
the patient has asked to have the operation performed and is 
simply awaiting a suitable time. 

In considering such a series of cases, it is at once obvious 
that the number is too small from which any positive conclu- 
sions can be drawn. At the same time there are certain features 
which are suggestive for application in the treatment of other 
cases. In the first place the lesion seems peculiar to girls or 
young women. It develops at the period of rapid growth, 
from twelve to sixteen years of age. It may develop either 
with or without violence. It is usually associated with flat 
foot, which is probably a factor in the development of the weak- 
ness of the knees. True knock-knee is sometimes present. 
In all of the cases the tubercle of the tibia was displaced farther 
to the outside than normal, so that the line of pull of the quad- 
riceps muscle contained a distinct angle. In the extreme cases 
without treatment the dislocation may become permanent, 
as in Case 1. 

It seems probable that, if the condition is seen in the begin- 
ning, and the flat foot corrected, together with such treatment 



308 RECURRENT DISLOCATION OF THE PATELLA. 

as would tend to improve the general tone, the trouble can be 
corrected without operation. This has not been possible in any 
of the cases seen by me, but on general reasoning it seems prob- 
able. 

If, on the other hand, the dislocation has recurred several 
times, and the period of osseous growth has passed, the weak- 
ness will probably increase unless the faulty mechanical feat- 
ures are corrected by operation. 

If an operation is to be considered, the chief point to be borne 
in mind is the straightening of the line of the pull of the ante- 
rior thigh muscle. This is best accomplished by transplanting 
the outer half of the patella tendon, so that it is attached well 
tx) the inside of the tubercle of the tibia. If the tendon be too 
long, it can be shortened at the same time the attachment is 
made. The relaxed capsule is undoubtedly a result of the 
mechanical pull, and can be entirely ignored, the relaxation 
disappearing as the strain is removed. Of the cases treated, 
seven were operated upon and two of the others are awaiting 
operation. Of the operated cases, four had the outer half of 
the patella tendon and one had the entire tendon transplanted 
to the inside; and, as three had both knees treated, there were 
eight operations with normally strong joints in seven, the ulti- 
mate result in the eighth being uncertain, as sufficient time has 
not elapsed since the operation. Of the three cases in which 
other operations were performed, in one with both knees the 
capsule was quilted, in one the patella tendon was shortened 
without transplantation, as well as quilting the capsule, and in 
one the inner half of the tendon was transplanted as well as quilt- 
ing the capsule. All relapsed. In one of these a second operation 
with the transplantation of the outer half of the tendon was 
performed with a perfect result. In both of the other cases I 
am very sure that, if another operation could be performed and 
the tendon transplanted, as has been described, the mechanical 
feature which makes the dislocation possible would be removed, 
so that the slipping would cease. 



VIII. 
AN UNUSUAL CASE OF POTT'S ABSCESS. 

STEWART LEROY m'CURDY, M.D. 

A young man aged eighteen had an acute periostitis of anterior 
surface of maxillary bone, which was followed by infection of 
orbital cavity with complete destruction of the eyeball. Sec- 
ondary infections developed, the most important one being 
destructive disease of the lower dorsal vertebra, which ran an 
acute coimge. The destructive process extended over a period 
of three years. An abscess developed, which occupied the left 
half of the abdominal cavity. A cough had developed, and 
considerable pus was expectorated. It was not thought that 
the abdominal abscess had anything to do with this, but it was 
instead concluded that there had been a secondary deposit in 
the limgs. 

The abscess appeared below Poupart's ligament, and was 
incised. It was irrigated daily with peroxide of hydrogen. 
The cough was exaggerated sufficiently to suspect that there 
might be some communication. 

Methylen blue was added to sterile water, and irrigation of 
the cavity from below Poupart's ligament is causing the patient 
to expectorate the coloring matter, showing conclusively that 
there was a continuous passage from the anterior surface of 
the thigh through the abdomen, limgs, air passage, and mouth. 

The case is reported for record. 

Presented at the Seventeenth Annual Meeting of the ABSOoiation. Washington. 
D.C.. Biay 11-14, 1908. 



ABSTRACTS. 



SCOLIOSIS. 

141. A Contribntion to Animal Scoliosis. From Profeflsor Vulpius's Sund- 
cal Orthopedic Institute, Heidelberg (19 illustrations, 3 references). By 
Dr. Ottendorf , First Assistant. ZeiUehr. f. arth. Chir., Bd. XI. s. 803-826. 

The author studied in careful detail, so far as the preparation of the soeci- 
mens permitted, eleven cases of aninial scoliosis from the veterinary scnool 
at Hannover. The histories of the specimens were not obtainable. 

These cases presented pathological pictures so similar to human scoliosis 
in their variety that Ottendorf was led to infer that similar influences had 
caused the development of the curves, rotation, etc., in spite of the absence 
of vertical functional weiffht-bearing as a factor in the case of the animals. 

He classified them as follows: — 

I. Congenital. 

(a) Supernumerary half vertebra (horse). 

(b) Pressure owing to lack of room in uterus (3 goats, 1 calf, 2 

imknown). 
II. Acquired. 

(a) Rachitis (pig). 

(6) Habit (?), (bullock). 

(c) Deformine spondylitis (plastic inflammation of bone substance, 

bullock). 

(d) Ankylosing inflammation of vertebrae and ligaments, Marie 

type (bullock). 

Ottendorf quotes approvingly Zuppinger's theory that side pressure on the 
front of the chest starts rotation by rio leverage. The static influences coming 
in later serve to increase and fix the deformity in case of plastic bones. Some 
of his cases serve especially well to illustrate this process by inference, as fol- 
lows: — 

An animal lies down much during a prolonged illness, and soon lies chiefly 
on one side, as most comfortable. During tms time the bones are soft and 
plastic. Rotation is started by the side pressure on front of chest; and the 
curve, wedging of vertebrae, etc., follow in natural sequence. 

Ottendorf infers in one case, in which not only the vertebral bodies are 
ankylosed, but also the spinous processes (and which he classes as congenital), 
that the fusion of the spmous processes occurred first, thus locking the verte- 
brsB together, so that continued growth of the bodies caused them to crowd 
out into a form in which they were also fused together later. The lordosis 
shown by the specimen is consistent with this explanation. — O. W, FiU, 
Boston, 

14a. A Defence of the Hessing Corset. By Dr. Carl Haselrock. ZeiUchr, 
orth. Ckir,, Bd. XI. Heft 4, pp. 776-780. 
Dr. Haselrock takes exception to Becker's unfavorable criticism -of the 
Hessing corset in the first number of the Arch. /. Orthop. Mechamtherap u. 
Unfall Chir,. and enthusiastically claims for it superiority to a stiff corset 
(of leather, telt, steel) in scoliotic and other cases on all points except that 
of corrective force in rotation. He bases his clauns on a large practical 
experience in the use of the corset, having furthermore in many mstances 
replaced the stiff kinds by the Hessing. — O. W, Fitz, Boston. 



ABSTRACTS. 311 

i43« The Present Status of the Treatment of Lateral Curvature. N.Y, 
Med, Record, Dec. 5, 1903. By Jacob Teschner. 

J. Teschner adduces evidence corroborating his views advanced some years 
ago regarding the efficacy of g3muiastics in the treatment of latend curvature 
of the spine. He criticises rather severely other writers for tUbir statements, 
and for advocating other methods of treatment, even though his be men- 
tioned. Several figures accompanying the paper illustrate tne good results 
of muscular efforts in the correction of markea deformity of the spine. The 
point most strongly emphasized ia the necessity of the personal supervision 
of a physician who understands the method. Sending patients to ordinary 
gymnasiums is almost always of no practical benefit. — AM, Am, Med, 

SPINE. 

Z44. Tabetic Osteoarthropathy of the Vertebral Column. By Dr. Graetser, 
GOrlits. DetUeeh, med. Woch., Dec. 24, 1903. 

Dr. Graetzer comments upon the infrequency with which tabetic osteo- 
arthropathy of the vertebral colunm appears in the literature, — only deven 
cases of this in several hundred cases of osteoarthropathies. 

He describes a case treated at G<>rUtz, as well as the X-ray picture which 
accompanies it. 

He alludes briefly to the cases described by Pitres and Vaillard, Abadie, 
and KrOnig. 

Treatment was by the Hessing-Hoffa cx>rset, with relief. — David Townsend, 

Z45. The Treatment of Paraplegia in Tuberculosis of the Spine. Some Sug- 
gestions and a Review of Recent Work. By J. Jackson Clarke, M.B. 
Lond., F.R.C.S. The Practitioner, London, September, 1903. 

The article is illustrated by two skiagraphs which show the character of 
the thickening produced in spinal caries. There are also several instructive 
cuts of apparatus. 

Mr. Clarke states that, when paraplegia supervenes in the course of spinal 
tuberculosis, the seat of disease is genertQl3r at or above the mid-dorsal region. 
Rest in either the prone or recumbent position is not uncommonly successful 
as a method of treatment. Some cases, however, present rapid onset with 
supervening myeUtis; and here operation must be resorted to without delay. 

In order to get a clear idea of clinical conditions, the following grouping 
of cases is made: — 

1. Cases in which the paraplegia (chiefly motor) comes on gradually, and 
gradually disappears when the patient is put to bed. 

2. Cases in which the paraplegia (chiefly motor) persists, in spite of rest 
in bed with extension of the spine. 

3. Cases in which the parapfegia develops rapidly, is both motor and sen- 
sory, and, if not soon relieved, passes into mvehtis with bed-sores. 

4. Aberrant cases; e,g,, where pressure is due to bone, and not, as is usual, 
to the formation of solid or Uquia tubercular matter, at the front of the spinal 
coiti. 

Laminectomy is then discussed as an operative procedure. The cases 
of W. Arbuthnot Lane (1890-91) are rehearsed in detail, — eight cases in all, — 
with the following results: one relapsed; one showed no sicn of improvement; 
five were permanently relieved; one died from rectal po^pus. The author 
presents the following objections to laminectomy: sound arches of the spine 
are removed at the seat of disease; tubercular matter is evacuated by a route 
which exposes the whole circimiference of the cord to tubercular invasion. 

Forcible correction of the angular deformity: Mr. Clarke has abandoned 
this as a haziardous proceeding, though he at one time favored it in a case 
that had resisted treatment by a years rest in bed under the most favorable 
circumstances. 



312 ABSTRACTS. 

C. B. Keetley (1890), after doing a laminectomy on a boy of fourteen 
years, did also a "lateral trephining." This case was unproductive of good 
results, and Mr. Clarke regaros this operation as a dangerous one in ordinary 
hands. 

Menard {Reoue cPOrthppSdie, Nov. 1, 1894) recommended "costo-trans- 
versectomy" as a substitute for laminectomy, and reported two successful 
cases. He removed several transverse processes; but this, the author states, 
involves injurv to the pleura. 

Case A. — ^Here Mr. Clarke did laminectomy, and there followed tempo- 
rary improvement. In the course of ten days the paraplegia rapidly became 
complete, involving the bladder and sphincter ani. Guided by a sidagraph, 
Mr. Clarke did & costo-transversectomy, removing only the right transverse 
process of the eighth dorsal vertebra and the neck of the corresponding rib. 
lie sa3rs, ''I was strongly impressed with the fact that, had this second operar 
tion [costo-transversectomyj been performed in the first place, laminectomy 
would have been altogether unnecessary." The improvement was steEuiy, 
and the patient will soon be allowed to walk with crutches and spinal support. 
That the cord underwent some oi^anic change is evidenced by slight ankle 
clonus and the presence of Babinski's sign on both sides. 

Case B. — ^This patient was under observation in the hospital for eight 
months before the operation, the paraplegia gradually becoming complete. 
Costo-transversectomy was done directly, without a preceding laminectomy. 
The neck of the rib and the transverse process of the fifth dorsal vertebra 
were removed, the abscess cavity was 8crai)ed with a small Volkmann's 
spoon. It was necessary to repeat the operation to establish good drainage. 
The patient was walking well and naturally in less than eight months after 
the operation. 

The recital of this case before the Clinical Society of London encouraged 
Dr. W. H. B. Brook to perform costo-transversectomy. Mr. Clarke reports 
this case also. The result was that the patient could walk. 

Case C. — ^Here the operation, costo-transversectomy, was done first on one 
side; and, as no improvement resulted, it was then done on the other. When 
last reported, the patient had strong movements in the legs, but could not 
yet waik. 

Case D. — In this case, meningitis appeared shortly after operation; and 
the patient died. Mr. Clarke is of the opinion that he operated too early; 
e.g.f Defore the tubercular material had undergone liquefaction. 

The ages of these patients were, in order: Case A, 45 years; Case B, 4 yean; 
Case D, 4J; Case D, 16 years; Dr. Brook's case, 17 years. 

The following conclusions are made: — 

1. When paraplegia develops rapidly and involves sensory as well as motor 
functions, operative interference is necessary. 

2. In other cases tiy rest in bed with extension. If this fails, get a good 
skiagraph and drain the abscess, preferably by costo-transversectomy. 

For bed treatment the Bradford frame is recommended. For a support 
either the Taylor or Chance brace is recommended: plaster jackets^ as a rule, 
will only supply support up to the seat of deformity. — Nathamd AUUan, 
St. Lams, 

146. A New Method of Applying the Plaster Jacket, and a New Stretcher 
for the Recumbent Treatment of Spinal Tuberculosis. By S. J. Hunkin. 
Appliances for the treatment of spinal tuberculosis are of value in proportion 
as tney confer immobility, and shift weight from the diseased area. This is 
best accomplished by leverage, thereby mcreasing weight borne by articular 
processes; for, fortunately, these surfaces, unlike what occurs in other joints, 
are rarely affected by tuberculosis. No apparatus is made that can support 
body by lifting, on the principle of the double. Such furnished support would 
be impossible after the first few hours by the body adapting itself. All appa- 
ratus must be considered as antero-posterior levers, and are efficient only as 
they force the transmission of the superincumbent weight to a plane post^ior 



ABSTRACTS. 313 

to the diseased area. This manceuvre being easy to accomplish where the 
nonnal curve of the vertebral bodies is convex anteriorly and hard where the 
normal curve is concave anteriorly, these curves can be somewhat changed 
in extent and the lever efficiency increased. 

In winter of 1897 and 1808, at the Children's Hospital, San Francisco, an 
endeavor was made to increase the efficiency of the straight jacket b^ cutting 
it through after it was hard alon^ the curve of the ribs, m the antenor three- 
fourths of its circimiference^ leavmg it intact posteriorly at the kyphos level, 
either springing it apart in front, 4 or 5 and even 6 cm. This procedure, while 
tiresome, gave greater efficiency in the Jacket. Lately a somewhat similar 
result has Deen secured by using a modified apparatus of Goldthwaite, and it 
is this instrument which was shown. 

There is an essential difference in the mechanics of this instrument, com- 
pared with the suspension sling. The latter straightens the spine, the origi- 
nal intention beinf support by lifting; while the former increases the curve 
of the colunm, and endeavors to promote a long posterior curve, giving sup- 
port by leverajge. It has no advantage in luim>ar disease, but in the mid- 
dorsal region its greater capacity is manifest; and the extent of efficiency 
of the pkuster jacket is increased upwards at least two vertebrae and in just the 
region where the old appliances are faulty. 

There is also presented a stretcher splint for the reciunbent treatment of 
spinal tuberculosis based upon the same principles, and the outcome of the 
instrument before shown. It is primarily the Bradford gas-pipe frame, but 
curved in its length, so that its superior surface Lb convex. Tne curve can be 
changed both in position and altitude. No provision for traction is provided, 
that being considered unnecessary in the majority of cases and in many 
harmful. Children are quite comfortable on the stretcher, and often express 
relief on it after having been on a straight stretcher. — Ahst, Transactions of 
Medical Society of the SiaU of California, 1899. 

147. Acute Osteomyelitis of the Vertebral Column. By Dr. Grisel. Revue 
(TOrth., Paris, September, 1903. 

But 41 cases of acute osteomyelitis of the spine were collected and reported 
bv Dr. Hahn up to 1899. Dr. Urisel adds a few more collected and two cases 
observed on the service of Professor Kirmisson at the Trousseau Hospital. 

There is a detailed accoimt of these two cases, then a review of the subject. 
Lannelongue in 1879 reported the first complete description of the affection. 
Subsequently other cases of his were published. 

Grisel found 64 reported cases, but reduces the number to 56 after careful 
investigation. There were then 8 of a doubtful nature. In some cases a 
typhoid condition comes on, and the local condition is comparatively masked. 
There is^ however, the local rigiditv, abdominal or thoracic pain. 

In another form the process is slower, the local symptoms are more marked 
and attract attention, while the general process is less prominent, age varies 
from 9 to 12 years, overwork, trauma followed by local pain, more often in 
the lumbar region. The pain increases, the spine is held rigidly at the seat 
of disease. Tlie patient appears ill. and has to go to bed. Tiie patient is 
sent to the hospital often with the diagnosis of typhoid, pneiimonia, pleurisy, 
or peritonitis. 

At first there are stiffness, tenderness, and pain without signs of fluctuation. 
Then swelling comes on slowly, with cedema and prominence of local veins. 
In about ten da}r8 there is a temperature of 39^ and locally deep fluctuation. 
Incision and drainage is indicate, and the vertebrae are found denuded of 
periosteum. Laminectomy is sometimes necessary. Persistent fistuks 
are exceptional. In the 56 cases, 53 are carefully reported: 30 died, 23 re- 
covered. » 

Region of Deformity, Recovered. Died, 

Suboccipital 1 4 

Cervical 2 2 



314 ABSTRACrrS. 

Region of Deformity. Recovered. Died, 

Dorsal 7 3 

Lumbar 13 15 

Sacral 6 

Sacral cases all died. 

Occipital, four-fifths died. 

Dorsal, one-third died. 

Lumbar and cervical, one-half the cases died. 

Affected Area. Recovered, Died. 

Body of the vertebra . . . • 7 22 

Arc of the vertebra 16 8 

In affections of the arc two-thirds recovered. 
In affections of the body one-third recovered. 

EnoLooT. 

Age. Number. Age. Number. 

0- 5 years 7 16-20 years 6 

6-10 " 12 21-25 " 4 

11-15 " 14 26-30 " 5 

Boys, 34; girls, 14. 

The cases where bacteriological examination was reported were classed 
as follows:— 

Staphylococcus aureus 13 

Staphylococcus albus 1 

Streptococcus 2 

The three combined 1 

Tetragenous 1 

Osteomyelitis of the spine follows the general rule, and the staphylococcus 
aureus is the most frequent cause. 

Osteomyelitis of the body vertebras 19 

Osteomyelitis of the posterior arc 21 

Osteomyelitis of the whole vertebra 3 

Rigidity and spasm are constant, but deformity is not common. Only 
5 cases in 56 show any deformity. 

The line of abscess, the pressure on the cord, the presence or absence of 
meningitis, is studied and classified. SequelsB and complications are noted. 
A careful detailed review of the disease is systematically made. The article 
is well worth reading. — Robert Soutter, Boeton. 

X48. Acttt« Spinal Oateomyelitia. By Dr. Grisel. Rev. d^Orth., November, 
1903 (concluded). 

This disease is as common in the {>06terior arc as in the body of the vertebr9> 
while tuberculosis is nearly always in the body vertebrse, a posterior affection 
being the exception In Pott's disease. In 21 cases of disease in the posterior 
arc. none were m the cervical region; 6 were dorsal ; 15, lumbar. 

Osteomyelitis of the body of the vertebra is of a more serious nature than 
that of the posterior arc. 

In 22 cases there were 14 deaths and 8 recoveries. In these cases there 
are but two alternatives, incision and drainage, followed by rapid recovery 
or death. 

There are but 3 cases of osteomyelitis of the bodies in the cervical region. 



ABSTRACTS. 315 

Two caaes were complicated by absceas in the spinal canal. The abscess 
may often be felt when anterior. In this region the involvement of the nerve 
centres makes the disease quite serious. 

There were 5 cases of oisease of the bodies in the dorsal region, with 3 
deaths. Dorsal osteomyelitis is then very fatal. Of the 2 cases that recov- 
ered, 1 developed a permanent fistula, the other a myelitis, making the prog- 
nosis extremely bad for all cases. The liunbar region is the common plaoo 
for both anterior and posterior osteomyelitis. 

Dr. Grisel collected 14 cases of osteomyelitis of the lumbar bodies. Only 
4 cases recovered. The disease here takes the form of a phlegmonous perios- 
titis. Cure is affected in those cases where the abscess is incised and is found 
to be superficial, and not extensive. As a rule, the disease in this region is 
apt to imiltrate with pus the spinal conal or the l\unbo-sacral or lumlK>-iliac 
muscle groups. 

There were 5 cases of osteomyelitis of the atlas and axis. Death comes 
from general infection. 

Meningo-encephalitis. The complications make the disease in this region 
particularly serious. 

There were 7 cases of sacral osteomvelitis, with only 1 recovery. This 
1 case was superficial, though considerable pus coUected in a very short time. 

Treatment is carefully considered for each locality, — i.e,, for the anterior 
or posterior arc in the cervical, dorsal, lumbar, sacral, or axio-atloid regions^ — 
and is based on the outcome of the cases wmch were examined at operation 
or post mortem. In some regions, incision and drainage of abscess have 
proved sufficient, while extensive operations failed to give results. It is 
noteworthy that 40 out of 56 cases died from general infection, complications 
of pleuro-pneumonia or meningitis, before the diagnosis was made and be- 
fore abscess had formed to indicate operation. It is of interest also that 
simple incision of the abscess without extensive operation preceded every 
case that recovered. 

This article of Dr. Grisel must have entailed a great deal of work and the 
most patient consideration of detail. It is interestingl]^ written, doubtful 
cases are eliminated, the material of value in each case is carefully classed, 
and the reader allowed to draw his own conclusions. — Robert Soutter, Boston. 

149. Hystero-traumatic Kyphosis. By Del^aide. Gdjr. [dea Hdpitaux, No. 
75, 1902. 

Treats of etiology, symptoms, pro^osis, and therapy of the so-called 
Brodie's disease. Recommends the epidural injection of 1 per cent, cocaine 
and the application of ethyl chlorid to the spine. His patient was cured in 
twenty mmutes. — AJbst. Zeitschr. /. orth. Chir., xi. 3. 

150. Spinalgia as an Early Symptom of Tuberculous Infection. By J. 
Petruschky. Muen, med. Woch., 1903, No. 9. 

Petruschky has noticed that "pains between the shoulder blades" is a 
frequent complaint of persons who later exhibit symptoms of tuberculosis. 
He thinks that thev have some connection with a primary tuberculous in- 
flammation of the bronchial glands, and can therefore be accepted as one 
of the earliest signs of the infection. At a recent autopsy he discovered recent 
secondary infection of one apex, with evidences of old tuberculosis lesions 
in the bronchial glands, although nothing during life had suggested the pos- 
sibility of tuberculous infection, and the child nad died from scarlet fever. 
He affirms that it is possible to detect the presence of the primary bronchial 
involvement by the spinalgia referred to above, the typical sensitiveness 
to pressure of certain verteors between the second ana seventh dorsal. 
They show a trace of lordosis usually, and appear to the finger to be a little 
broader, softer, and more elastic than their fellows. The symptom is val- 
uable only when these spinous processes are distinctl]^ more sensitive to press- 
ure than the others. The diagnosis of tuberculosis was confirmed by the 



316 ABSTRACTS. 

tuberculin test in all but 2 out of 79 cases of this spinalgia, while none of 
them developed a spinal affection. 32 were children under sixteen, and 
45 were adufts. In only 14 were any signs of tuberculosis to be discovered 
in the lun^ at the time. On the other hand, spinalgia was scarcely ever 
observed m advanced tuberculosis. Primary infection of the bronchial 
fflands is a more dangerous lesion than when the glands in the neck are af- 
^cted, although infection from the latter is liable to spread to the bronchial 
glands at pubertv. Petruschky is an advocate of tuberculin treatment as 
the most rational and certain of all means of preventing general infection 
from glandular lesions. — Ahst. Jovr. Am, Med. Aas'n. 

15X. Spondylitis Deformans. By John Rurah, M.D., Baltimore, Md. Am, 
Jour. Med. Sciences^ November, 1903. 

Rurah reports a typical case of spondylitis deformans in a woman twenty- 
two years old, in which the entire spine, the shoulder joints, and hip joints 
were affected. 

He describes bony deposits in or imder the muscles of the neck, close to 
the vertebrae, which could be felt. 

The literature of the subject to date is very carefully reviewed and analysed, 
and the history, nomenclature, etiology, and pathology studied in detail. 
The important points in diagnosis and differential diagnosis are fully brought 
out. 

Photogre4>hs of specimens in the Museum of the College of Physicians 
and Surgeons, Baltimore, are given. An extensive bibliography of the sub- 
ject is appended. — John L. Porter, Chicago. 

BONES AND JOINTS. 

15a. The Distribution of the Nutritive Arteries of Bone and its Relation 
to Disease Foci. By Lexer. XXXII. German Surgical Congress. 
CefUr. /. CMV., 1903, Suppl. 
Why tuberculous and suppurative processes are localized with particular 
freauency in certain bones or segments of them has not yet found satisfactory 
explanation. Tuberculous infarctions indicate some relation to the circu- 
lation of the bones. This he attempts to show by means of mercurial injec- 
tions of the bones of new-bom and youn^ children. 

The conclusion is drawn that all foc^ bone diseases which are connected 
with the circulation depend for their localization upon the distribution 
of the arteries, that they therefore are produced by clumps of bacteria or 
infective emboli. Infarcts arise in such places only as have end arteries. 
The fact that the embolic process is more frequent in tuberculosis than in 
suppurative disease explains the difference in frequency of the part of the 
bone affected in these two diseases; e.^., the joint ends and the short hollow 
bones. The frequent occurrence of such embolic processes in the bones of 
the young can at present be explained only by their relatively greater vas- 
cularity. — A. H. Freiberg y Cincirmali. 

153. Congenital Dislocations of the Radius. By Charles A. Powers, A.M., 
M.D., Denver. Jour. Am. Med. A»«'n, July 18, 1903, xli. 165, No. 3. 

The writer describes a case of congenital dislocation of the radius in a boy 
thirteen years old, and discusses other reported cases. Two photograpiis 
and a skiagraph accompany the text. He concludes that absence of pro- 
nation and supination is the most characteristic symptom. — R. B. Osgood, 
Boston. 

154. Treatment of Inveterate Fractures of the Patella. By Schanz. Trans. 
XXXII. Germ. Surg. Congr. CenJbr. f. Chir., 1903, Suppl., p. 157. 

Case five years' standing, with 12 cm. separation of fragments. No power 
of extension at knee. The sartorius was loosened at the lower part of its 



ABSTRACTS. 317 

belly, but without seveiinff its bony insertion. A vertical eroove was chis- 
elled into the anterior suruuse of the fragments, and the belly of the muscle 
sewed into this eroove. After six weeks in plaster the patient was able to 
climb stairs, and finally regained power of extension completely. — A. H, 
FreSberg, Cincinnati. 

XSS" Osteoma of the Knee Joint. By R. T. Taylor. Annals of Surgery, 
January, 1903, p. 84. 
Taylor reports a case of osteoma of the knee joint to emphasize the great 
importance of the skia^am by making the diagnosis possible in such cases, 
and the value of the A-ray in pointing out the proper mode of treatment 
when the foreign body is not palpable. Three X-ray pictures of the case in 
question were taken, showing the foreign body in the joint, which protected 
over and into the intercond3rlar notch. The X-ray stereoscope showea that 
it was attached to and near the external side of the internal condyle. At 
the operation the foreign body was seen occupying a position between the 
condyles, as shown in the skiagram. — R, B. Osgood, Boston, 

156. Bony Changes in Gonorrheal Arthritis. Wien. klin, Woch,, Jan. 15 and 
22,1903. 
R. Kienbock has observed after injuries and inflammatory processes of 
extremities, especially after grave gonorrheal metastatic arthritis, changes 
arise in the skeleton, usually spoken of as "inactivity atrophy" of the bones, 
but more correctly considered as acute osseous atrophy. It also occurs after 
injuries and acute diseases of the nervoiis system. Pathogenetically, 
this atrophy is in line with other trophic changes, such as muscular atrophy, 

■ ot the 



ffipoviai changes, etc. It begins four to eight weeks after the onset of %,u^ 
disease, nearest the area of inflammation, radiating from it in different direc- 
tions. It usually affects only the spongy bone at first, the radiographic 
picture showing this through lighter shadows and slight changes in contour. 
The greater the absorption of lime salts, the lighter the picture. The diaphy- 
sis, cartilage, and the surrounding soft parts are affected later. The treat- 
ment should consist of massage, passive and active movements, faradism, 
and artificial passive congestion. Numeroiis photographs illustrate the 
stages of the condition. — Aost. Am. Med. 

X57. Some Remarks on Britement Porc^ etc. By Dr. Franz Staffel, 
Wiesbaden. Archiv /. orth. Chir., i. 2, 1903. 

When we use hrisemeni forc^, we tear. The less the actual growing together 
of the articular facets, the better our chances in such procedures. Bony 
bridges, as may be demonstrated by the X-ray. should warn us against hrise- 
meni Jord. A discussion of indications and tne injury done by the opera- 
tion follows. The value of the proceeding depends to a rreat extent upon 
the after-treatment. The best position of fixation in the elbow is the right- 
angled position; but. if we wish to preserve what motion we have gained, we 
must remove our nxation after twenty-four to forty-eight hours. How- 
ever, if we take off the splint at the end of that time, the fore arm sinks on 
accoimt of its weight. Passive motion causes ^reat pun, but whatever 
motion we get must include the position of a right angle on accoimt of 
the usefulness of the arm at that angle. According to tne writer the most 
advantageous apparatus in after-treatment is a splint with strong elastic, 
adjustable banos {Gummissug)^ which must be applied after the orisement 
fond. Such a course, in conjimction with baths, massage, and exercises, 
guarantees the best result; namely^ motion at a favorable angle. Its great 
advantage lies in the fact that motion can be maintained without pain. 

After orisement force of hands and fingers, such after-treatment is of equal 
value. Then follows a description of apparatus and a report of a case. — Henry 
Feiss, Cleveland. 



318 ABSTRACTS. 

258. The Frequency of Joint Affectione in Hereditary Syphilis. By E. 
Hippel. Muen. med, Woch,, No. 31, 1903. 

E. Hippel has found joint affections in hereditary syphilis frequent, espe- 
ciallv in cases which during their first years were insiimciently treated with 
antiluetic remedies. Individuals with parenchymatous keratitis usually 
belong to this class. Of 77 such {Mtients, 56 per cent, presented joint lesions. 
In most of them the ocular and joint diseases existed either simultaneously 
or the arthritis preceded the ociilar disease. The knee joint was oftene^ 
the seat of the oisease, and in nearly all cases both joints were the seat of 
a serous effusion of long standing. As the lesion usually occurs between the 
fifth and twentieth year, and is often imassociated with other signs of syph- 
ilis, the diagnosis may be almost impossible. Subjective sjrmptoms are very 
rare. A positive dif^osis can a}wa3rs be made with antiluetic treatment, 
which produces a cure in almost every instance. — Ahst. Am, Med. 

259. Traumatic Separation of the Bpiphysea. By Dr. Eugene Joiion, Paris, 
Bev. d^Orih., November, 1903. 

Dr. Joiion reports three cases of traumatic separation of the epiph^'as, 
one of the upper end of the humerus and two of the lower end of the radius. 

Joiion makes a careful reduction, and puts the limb in plaster of Paris for 
twenty to thirty days. Motion and massage and fear of ankylosis are of 
seoonoaiy consideration compared to the position. The great danger in 
these cases is deformity, functional disuse, and lack of growth of the bone 
from injury to the epiphysis. — Boheri Sautter, Boston. 

x6o. A Case of Substitution of a Piece of fyoiy for the Whole DimphjrsiB of 
the Radius. By Dr. Karl Vogel, Bonn. Deutach. med. Woch., Nov. 12, 
1903. 
Dr. Vogel briefly discusses the subject of bone transplantation, the sub- 
stitution of animal bone previously decalcified and sterilized, and the use 
of ivory as a plastic material in disease of the bone, as in cases where the 
bone is defective or entirely gone. He describes a case of a child of eight 
years where the diaphysis of the radius was destroyed, but the periosteum 
and ends of the radius remained, and a piece of ivory was substituted in 

5ubp 



its place. At the end of a year this showed a new subperiosteal growth of 
the epiphysis, as well as of the diaphysis. The article is illustrated by three 
X-ray pictures. — David Toumeend, Boston.' 

i6z. On Mueller's Operation in Spina Ventosa. By Dr. O. Erhardt, 
K6nigsberg. Muen. med. Woch., Sept. 29, 1903. 
Erhardt describes Mueller's operation for spina ventosa, which consists in 
substituting a periosteal piece of Done, chiselled out of the ulna, for the dis- 
eased diaphysis. He mentions 6 cases of spina ventosa treated in the K5- 
nigsbei]g surgicid clinic, in which the periosteal piece of bone was taken from 
the tibia instead of the ulna, in order not to weaken too much the ulna. In 
all of the cases there was disease of a metacarpal bone : and in one there was, 
in addition, disease of the first phalanx of one of the fingers. Union was by 
first intention in all the cases, with good result. — David Townsend, Boston. 

z6a. Progreasive Subluxation of the Carpus. By Dr. J. Abadie, Montpellier, 
France. Revue d'Orth., November, 1903. 

In the case reported the ulna is subluxated backward, the hand is dis- 
placed to the radial side, the radius retains its relation to tne carpus. 

The first row of carpal bones are in slight dorsal flexion on the second row. 
The lower curve of the radius is concave forward. 

The ulna is normal in its upper two-thirds, but curves toward the radius 
in its lower one-third. 

The subluxation of the wrist is the most noticeable thing, together with 
the shortening of the fore arm and exostoses of the radius. 



ABSTRACTS. 319 

The case is studied minutely, and the literature is reported and tabulated 
in an interesting manner. 

The collected cases are divided into those where normal relation of the 
radius and carpus is preserved and those with loss of these normal relations. 
Nearly all the cases are associated with deformity or hypertrophy of the ulna 
and abnormal curves of the radius. 

The cases with loss of the normal relations of the carpus to the radius are 
rarer and without bony lesions. 

These subluxations do not include those of traumatic or of inflanunatory 
oru^n. 

Treatment consists in apparatus, electricity, and massage, but generally 
osteotomy is necessary. — Rchert Soulier, Boston. 

z(^. Treatment of Surgical Tuberculosis. By A. Bobroff. Rousaky Vralch, 
ii.. No. 3, St. Petersburg. 
Seacoasl and Sun BcUhs in Surgical Tuberculosis. — Bobroff reports most 
gratifying results from the sanatorium for children which was established 
in Crimea, mainly through his efforts. The sea air in this balmy climate, 
the sun, and sea bathing are all important factors in the treatment of localized 
tuberculosis. He lays great stress on direct exposure of the site of the lesion 
to the sunshine, protected merely by a sheet. — Absl. Jour. Am. Med. Ass'n. 

164. Application of Bone Fillings to Osteomyelitia. By N. Damianos. 
Wiener klin. Rundschau, No. 30, Vienna. 
Treatment of Osleomyelilis with Iodoform FiUing^ — Damianos illustrates a 
number of specimens and cases to support his assertions that chronic oste- 
omyelitis is essentially an affection of the spongiosa, which fact has been 
overlooked heretofore in treatment. In reality, the irregularly distributed 
foci of granulation are the principal cause of the development and persist- 
ence of chronic myelitis. The spongiosa should be removed far into sound 
tissue, and this has been rendered possible by Mosetig's filling. He exposes 
the bone with a semicircular incision, and turns back the flap of soft parts, 
which includes the periosteum. He then removes the tissues affected, far 
into sound tissue, and fills the cavity left with the iodoform mixture described 
in the Journal, xl. p. 1544. Damianos gives radiograms of a nimiber of 
patients thus treated with complete success, the limb functioning perfectly, 
free from pain and any tendency to recurrence of the bone affection. — Abst. 
Jour. Am. Med. Ass'n. 

265- Tuberculosis of the Joints. By C. Fernet. BuUeHn de V Academic de 
Mededne, Paris. 
Femet's experience has confirmed that of others in regard to the mani- 
festations of tuberculosis in the joints. They may assume an acute or chronic 
form, and they resemble in many respects those of articular rheumatism. 
They have been called, therefore, tuberculous rheumatism, tuberculous 
reeudo-rheiunatism, etc.; but he protests against these appelations as in- 
aicating a relationship to rheumatism which does not exist. It is more cor- 
rect to say articular tuberculosis, just as we say pulmonary tuberculosis. 
In other words, the tuberculosis may manifest itself in morbid series which 
parallel those of acute or chronic rheumatism in their localization in the 
joints or elsewhere. But the lesions have nothing in common except their 
site. They differ in causation, pathologic anatomy, and in their symptoms. 
They shoidd therefore be differentiated and entitled differently. 

166. A Case of Osteitis Deformans with Heart Complications. By Charles 
J. Foote, M.D., New Haven, Conn. Am. Jour. Med. Sciences, Novem- 
ber, 1903. 
The author describes a case of osteitis deformans, with photographs, which 



320 ABSTRACTS. 

was under obflervation in the New Haven Hospital for five years, where he 
was admitted for treatment for valvular heart disease. 

The osteitis affected chieflv the head, spine, ribs, clavicles, and tibis. 
The circumference of the head at the hat-band was 25| inches, and he wore 
an 8^ hat ; while there was a depression in each parietal bone 5 + 6 cm., re- 
sembling a collapse of the skull. 

The spine had a marked long dorsal kyphos. 

The nbs were prominent and enlarged. 

The clavicles were very large, especially at the acromial ends. 

The tibiffi showed the most marked enlai^gement, especially about the 
tuberosities. — John L. Porter, Chicago. 

X67. QonorrhoBa in Inlants, with a Report of 8 Cases of Pyaemia. By 
Reuel B. Kimball. Med. Record, Nov. 14, 1903, vol. bciv.. No. 20. 
R. B. Kimball's conclusions are as follows: 1. Gonoirhcea previuls among 
infants and children to an extent not fully appreciated by the profession, 
and has become a common epidemic in institutions where numbers of chil- 
dren are placed together. 2. The ordinary clinical forms which the gonoooc- 
cus infection assumes in children are ophthalmia^ vulvovaginitis, and pyiemia. 
3. A series of cases of pysemia, reported in this paper, occurred in mfants 
in whom no local lesion could be found to explain the mode of entrance of 
the organism to the general circulation. 4. The suggestion is made that 
from a stomatitis due to the gonococcus such a systemic infection may arise. 
Gonorrheal stomatitis in infants is a disease that needs further study. 5. 
Only by careful exclusion, by microscopic examination, and bv complete 
isolation can this disease be absolutely aebarred from a hospital where in- 
fants are cared for. 6. There is urgent need of public enlightenment on this 
subject. Those in charge of institutions for cnildren. trained nurses, and 
even parents, should be taught the frequency and virulency of this infection 
and tne ease with which it is spread. — Ahst. Am. Med. 

CONGENITAL DISLOCATION OP THE HIP. 

x68. Congenital Dislocation of the Femur Treated by Subtrochanteric Osteot- 
omy. (Kirmisson's Operation.) By Dr. Froelich, of Nancy. Rev. 
d^Orth., September, 1903. 

In cases under seven bloodless reduction is generally indicated. Palliative 
treatment is sufficient for luxations without much functional disturbance. 
Such treatment would consist of corsets, high sole, massage, forcible abduc- 
tion at night. These are often sufficient as for palliative treatment. 

However, in bilateral cases with much displacement upward, marked 
adduction and lordosis, standing becomes very tu-esome and even painful. 

Subtrochanteric osteotomy tor congenital dislocation of the type here 
reported was introduced in 1892 by Kirmisson, and later adopted by Hoffa 
and Schwartz. 

In the two cases here reported pain was a marked feature, there was extreme 
lordosis, and great difficulty in walking. 

Case 1, nine years old. — Lordosis extreme, left lumbar, right dorsal 
scoliosis. Hips rotated inward, knees flexed, legs rub together in walking. 
Child needs support in standing. 

Case 2, seven years old. — Hips flexed^ knees flexed, hips dislocated high 
and backward, the trochanters approachmg the sacrum with marked adduc- 
tion, walking was almost impossible. Extreme lordosis, and right dorsaJ, 
left lumbar scoliosis. 

After six months^ cases could stand nearly all day, walking was fairly good, 
there was no pain m standing and no support was reouired. Patients stand 
straight without lordosis. There was a limp, due to tne ankvlosis. 

In doing the operation, subcutaneous tenotomy of the adductors is gener- 
ally advisable. 



ABSO-RACTS. 321 

The operation on both sides corrects adduction, the patient can keep clean, 
walking is made easy, the legs are rendered the same length, lordosis is cor- 
rected. 

Pain was entirely relieved. — Rcbert Soutter, Boston. 

169. On the Functional Improvement of Defective Hip Joints. Zeitachr, 
orlh, Chir, 

In this paper Professor Lorenis discusses chronic pathological conditions 
of hip joints, which, while due to different causes, present the conmion feature 
of imperfect function. The limp is of secondary miportance. 

He discusses dislocation of the hip due to coxitis, congenital dislocations 
of the hip which have passed the age when reposition is possible, cases of 
arthritis deformans coxae, and old ununited or badly united fractures of the 
neck of the femur. After discussing the ultimate results of tuberculous 
coxitis. Professor Lorenz says, ''If we cusregard the small percenti^ of coxites 
which get well with a restitutio ad irdegrum, the preceding investigation leads 
to the necessary conclusion that the strongest possible at best oony anky- 
losis of the hip in indifferent position (complete extension without abduction 
or adduction) represents by far the most desirable result of coxitis treatment 
as well for the endurance as for the cosmetics of function, and just that 
method of treatment would be the best which should most frequently lead 
to this sort of ankylosis." 

It is very rare indeed that patients suffering with congenital dislocations 
of the hip reach a ripe age without discomfort, and without being more or 
less disabled. 

Respecting the third class of cases, interest attaches here to the beginning 
cases of artmdtis deformans, the clinical investigation of which is frequently 
confined to limitation of aoduction, and to the fart that one can palpate 
a portion of the posterior surface of the femoral head by forced adduction, 
flexion and extension being entirely free. In these cases,' involvement of the 
joint is foUowed very quickly by weakness, and pain on motion, with a grad- 
uaUy increasing limp. The Roentgen picture gives the impression that the 
acetabulum is become too shallow to completely enclose the nead. The outer 
portions of the upper surface of the head appear outside of the upper rim of 
the acetabulum. 

Cases of the fourth class give the impression that the tissue uniting the 
fracture-ends has stretched under the influence of the body-weight, for the 
femur receives scarcely any recognizable support from the acetabulum. 
The palpating finger can recognize neither the femoral neck nor the head. 
In its functional aspect the condition resembles a luxation. "If one dis- 
regards the broken-off head of the femur, one car speak of a luxation of the 
upper end of the femur^ or rather of a luxation-fracture." 

Finally, old traumatic hip-ioint dislocations which have successfully op- 
posed reposition may be included in these categories, but of such cases liOrenz 
nas no experience. 

Functionally d^ective hip joints are usually treated by one of two sur- 
prisingly different methods. On the one hand, they are supplied with por^ 
tative apparatus. On the other, an operation is attempt^ by which the 
loosened connection between the pelvis and the upper end of the femur is 
made as firm as possible. Apparatus diminishes or does away with pain 
on walking. Endurance is not appreciablv increased. Disadvantages are 
the unsightliness of the treatment, tne drucigery, the expense, as welfas the 
fact that the patient becomes "a slave to his crutches." 

The operative procedure partakes of the character of a joint resection. 
The bony surfaces which are in contact are freshened in order to obtain a 
bony or strong fibrous union . Disadvantages are the severity of the operation, 
and, especially in older persons, the uncertainty of the result. 

His practical experience with the bloodless reposition of congenital dis- 
locations of the hip enabled Lorenz to recognize a middle way m treating 
these cases. Not infrequently pre-luxations occiu: directly upward under 



322 ABSTRACTS. 

the anterior inferior spine, or upward and a little outward beneath the an- 
terior superior spine, or outward, in which case the head does not sumwrt, 
as in the first two, the anterior pelvic wall, but pressed against the lateral wall 
of the pelvis. The head looks forward and lies below and without the anterior 
superior spine. Even in these last cases the functional result could have been 
much worse. The lordosis was corrected, the limp visibly diminishing, the 
endurance during walking correspondingly improved. After-treatment con- 
sisted in exercises directed toward increasing flexion and hyperextension. 

"After these observations the idea occurrSl very soon to render defective 
hipe, which did not admit a radical cure, better able to sustain weight, and 
more enduring, through the causing of an ultra-physiological habitual atti> 
tude in hyperextension and abduction.'' 

The only new thing is the proposition to increase the desired abduction 
beyond the physiological limit and to combine it with a similar ultra-physi- 
ological overextension attitude. However, the proposal is new to employ 
tliis combined joint position for the betterment of the above-mentioned 
classes of defective hips and, it may be, others like them. 

In the treatment of unilateral cx>ngenital dislocations the subtrochanteric 
osteotomy offers an eccentric correction, and therefore compensates. It also 
results in a bend in the femur, and therefore in a shortenmg of the already 
much shortened limb. 

Hoffa's oblique osteotomy is dangerous because of the extensive opening 
of the medullaiy canal. 

In bilatend dislocations, Hoffa's double nearthrosis (amputation of femoral 
head and application of decapitated surfaces to iliac periosteum) greatly 
shortens the limbs. It mav result in bilateral bony ankylosis, but more 
likely in loose joints. Finally, it is one of the severest surgical procedures. 

The advantages of the anterior transposition are the absence of dan^r, 
more or less real lengthening, marked apparent lengthening through abduc- 
tion, correction of the lordosis, diminisned limp, the carrying ability and 
function markedly improved, and, finally, the patients readily consent to 
such an operation. 

The steps of the operation are stretching of the adductors, traction enough 
to pull the head down 2-3 cms., overextension, and, last, the head is .transposed 
forward to the neighborhood of the anterior superior iliac spine by a com- 
bined movement in abduction and overextension. Should a fracture of the 
femoral neck occur^ it will be incomplete, and will not prevent the immediate 
anterior transposition of the femoral head. A plaster of Paris spica, which 
includes the pelvis and thigh to the knee, maintains their mutual relation. 
A shoe with a high sole on the unaffected foot enables the patient to walk. 

After three to four months the abduction is almost corrected, a thickening 
of 1 cm. being sufficient for the sole of the opposite side. The overextension 
is not diminished. This second dressing is left in place three to four months. 

After-treatment extends over an interval of one to two years before the 
nearthrosis is become stable. It consists of passive and active g^onnastics 
directed to enabling the patient voluntarily to carry the limb far beyond 
the limits of abduction and overextension. 

Lorenz next reports similar experiences with fractures of the femoral 
neck in old persons, these being the only other cases of this nature with which 
he had ha«i practical experience. — James T. Watkins, San Francisco. 

HIP, DISEASES AND INJURIES. 

170. Operation in Hip-joint Disease without Shortening. By R. Preston 
Robinson, M.D. Am. Med., Nov. 14, 1903. 
The writer describes the operation as done on two cases, as follows: The 
trochanter and upper end of the femur are exposed by a lateral incision five 
or six inches long. The necrosed or carious bone is then removed entirely, 
together with all diseased tissues; but care is used to preserve the periosteum 



ABSTRACTS. 323 

in its entirety or in fragments. After the part has been thus thoroughly 
treated, the fragments of periosteum are stitched together with catgut to 
form a connection between the upper end of the resected femur and the rim 
of the acetabulum. The muscles and connective tissues are then stitched 
closely over the periosteum, and the wound left open to heal by granulation. 
Weight is applied to make and maintain extension of the leg, and it must 
be carefully watched for the first two weeks. The patients are allowed to 
sit up in bed after two weeks or so, and gentle movements of the leg are 
instituted daily to mould a new joint. 

In each case almost perfect function was obtained with practically no 
shortening. Skiagraphs showed the bone to have been re-established, and 
the results were in every respect favorable. Walking; was allowed after six 
months had elapsed, and during the interval extension was maintained by 
a brace. — J. T, Rugk, Philadelphia , Pa, 

KNEE. 

171. Congenital Hyperextension of the Knee. By Professor Kirmisson. 
Eev. cTOrth., Paris, September, 1903. 

In 1900 Drehmann collected 98 cases. The deformity is rare, more common 
among females, as is congenital hip; while club foot is more common in males. 

It was found to be double 44 times, single 54 times. 

Double congenital hyperextension is more frequently associated with other 
congenital malformations. 

Delanglade (of Marseilles) published a case of double congenital hyper- 
extension of the knees. Antero-posterior median frozen sections were made. 

The lower epiphysis of the femur was at an angle with the diaphysis of 
150^ open forward. Kirmisson differentiates congenital luxation of the knee 
and genu recurvatum. In luxated cases there is total or partial disuse of 
the articular surfaces. There is no contact of corresponding joint surfaces 
and angiilar position of the epiphyses on the diaphyses. This tilting of the 
epiphysis, the bending of the femur, show long standing malposition. 
Instead of a curve with posterior convexity, as in hjrperextension, the seg- 
ments remain parallel, and the upper end of the tibia is displaced forward, 
and there is a hollow, or depression in front of the knee. In congenital hyper- 
extension complete flexion is impossible, even under anaesthesia; but the 
flexion may be made to 45^, and held there by a guttarpercha apparatus 
for four weeks. Massage and gentle forceful flexion will increase this to 90°. 
During the process there may be rupture of many fibrous adhesions, with 
ecchymosis about the knee. Further massage and passive motion will in- 
crease the flexion beyond a right angle. — Robert SouUer, Boston. 

172. The Isolated Rupture of the Crucial Ligaments of the Knee. By Dr. 
Pagenstecher, Elberfeld. Deutsch. med. Woch., Nov. 19, 1903. 

Dr. Pagenstecher describes three cases of isolated rupture of the crucial 
ligaments of the knee. Two were of the anterior crucial, one of the posterior 
crucial. Treatment was by operation in all the cases, with good result. 

He speaks of the infrequency with which any observations upon the iso- 
lated rupture, or pulling out of the ligaments, of the knee are to be found 
in the literature. Hints has collected 34 cases of this: 27 were of the internal 
lateral ligament, 3 of the long external lateral ligament, and 4 of the crucial 
ligaments. 

He describes the action of the crucial ligaments and experiments to prove 
this. He also shows how difficult it is to produce this isolated rupture of the 
crucial ligaments on the cadaver. 

He quotes a case of Dittel's where the anterior crucial was broken by ex- 
treme overflexion of the knee. 

Sometimes movable bodies are found in the joint, following a lesion of the 
crucial ligaments. Pagenstecher describes 4 such cases collected by Barth 



324 ABSTRACTS. 

from various authors: 3 were at the origin of the posterior crucial, and 1 
of the anterior crucial at its femoral end. 

Pagenstecher seems to think that injury to the crucial ligaments occurs 
even more frequently than supposed, and that on account of their hidden 
position this condition is more easily to be guessed at than diagnosed. He 
advises operation, even if nothing more than an exploratorv one, and open- 
ing; of the joint, especially in those cases where there is a nail-joint without 
injury of the external ligaments. 

He concludes his article with a general discussion of the condition and of 
the treatment, and considers that a flail-joint| chronic arthritis, or osteo- 
arthritis, traumatic arthritis deformans, or possibly free bodies in the joint, 
may resuH after trauma of the crucial ligaments. ' He also has a few words 
to say on "trigger knee." — David Tawnserul, Boston, 



173. Repair of Ruptured Crucial Ligaments. AnnaU of Surgery, May, 1903. 
Mayo Robson reports that a miner of forty-one, by a landslide in a coal- 
pit, received an injury to the left knee. He was treated for six weeks in a 
nospital, and was later admitted to the Leeds Infirmary. The knee was 
swollen, but free from tenderness on manipulation. When the muscles 
were braced up, the bones were in eood position, but so soon a8 they relaxed 
the tibia fell backward until stopped bv the ligamentiim patellse. On manip- 
ulation the head of the tibia could be brought forward in front of the femur, 
and there was also very free lateral movement of the head of the femur. 
There was fluid in the joint and the patella floated. It was evident the cru- 
cial ligaments had been ruptured. The joint was opened by a large anterior 
U-shaped flap, which severed the ligamentum patelhe. Both crucial liga- 
ments were found completely ruptur^i, being torn from their upper attach- 
ments, and the ends being somewhat shreddy. They were sutured in posi- 
tion by means of catgut ligatures, the anterior being sutured to the svnovial 
membrane and tissue on the inner side of the external condyle, and the poe- 
terior, which was too short, and therefore split in order to lengthen it, was 
fixed by suture to the erynovial membrane and cartila^ on the outer ude 
of the internal condyle. The wound was closed, some pain followed the opera- 
tion, and there was considerable effusion into the joint. This was let out by 
removing a stitch, and progress was uneventful. Three weeks after the opera- 
tion plaster of Paris was applied, and he was allowed to go about on a Thomas 
splint. The plaster was removed after a month, ana massage instituted. 
Recovery was complete joint function being entirely restored. This opera- 
tion was in 1895, and in 18d8 an operation was performed on another ps^ient 
for a like condition, the result being equaUy satisfactory. — Ahst, Am, Med, 



SHOULDER. 

X74. Elevation of the Scapula with Congenital Defects of Neck and 
Shoulder Muscles. By Kayser. Deutech, Zeit. /. Chir., bcviii. 318. 

Case report (see also CenhU., 1901) with discussion of muscle defects in 
connection with elevation of congenital character. The case reported is uni<iue 
in presenting; the combined defect of left stemocleido^ part of left trapesius, 
and shortenmg of left clavicle. Cervical rib on the n^nt side in addition. 

Imp^ect descent of scapula in embryonal period is considered the like- 
liest theory.— Afe»(r. Centr. /. Chir., 1903, p. 982, A. H, Freiberg, Cin- 
cinnati, 

175. On Congenital Absence of the Collar Bone. With illustrations. By 
A. Gross. Muen, med, Woch,, No. 27. 
The defect was, as usual, accidentally discovered, as it showed no note- 
worthy appearance of deformity. There existed also other bone develop- 



ABSTRACTS. 326 

ment defects, so that the case is probably to be considered as a true arrest 
of development. — D. Townsend, BoUon. 

176. On the Freeing of the Contractions of the Shoulder Joint. By Pro- 
fessor Dr. A. Ritschl, Freiburg. Anikiv /. Orth., i. 1. 

The usual method of overcoming the contractions of the shoulder joint 
is partly manual and partly mechanical, and for the mechanical part Dr. 
Ritschl reconmiends, of the many kinds of apparatus, the one he and Dr. 
Beely constructed. He considers both the manual and mechanical methods 
necessary, but describes the technique of a purelv manual form of reduc- 
tion, where one pushes the sce4>ula oackward with one hand and with the 
other raises the arm laterally. This has the advantage that one does not 
have to think of the horizontally iSxed arm, and can concentrate his atten- 
tion more fully upon the movement of the scai>ula. This method can be 
used in the vertical as well as the recumbent position. — D, Townsend, Boston. 

177. Congenital Dislocation of the Shoulder. By Cumston. Am. Jour, 
Med, Sciencea, June, 1903. 

Cumston reports a case of congenital dislocation of the shoulder in a child 
five years old, operated upon in April, 1901, by the method advised by Phelps. 
The patient, wnen seen m June, 1902, had improved considerably in the use 
of the arm; and the result was considered most satisfactory. The writer 
reviews several published cases, and discusses all the theories of causation, 
of coi^enital dislocations, but adds nothing to our present knowledge. — 
John £, Porter, Chicago. 

FOOT. 

Z78. The Pathology and Treatment of Hallux Rigidus, Hallux Plexus, and 
Hallux Bxtensus. By A. H. Tubby. BrUish Med. Jour., Oct. 17, 1903. 
Tubby thinks that, notwithstanding the divers causes attributed in these 
affections, there is one cause which almost invariably underlies all condi- 
tions; namely, an osteoarthritis of the first metatarso-phalangeal joint. The 
structures concerned in this joint are the distal end of the first metatarsal, 
the proximal end of the first phalanx, its ligaments, and the two sesamoid 
lx>nes, with the synovial memorane. In these cases there is always found 
inflammation of the intersesamoid pad and synovial membrane with ulcer- 
ation of the cartilage. The sesamoids may also be diseased. As the condi- 
tion goes on, osteophytes make their appearance, especiaU3r from the base 
of the first phalanx, rendering flexion and extension impossible. In speak- 
ing of treatment, Mr. Tubby says that, in his opinion, excision of the head 
of the first metatarsal is undoubtedly the best proceoure, but that he pre- 
fers, as a rule, to content himself with chipping on the osteoarthritic growths. 
In the less painful cases, where it is not necessary to operate, careful atten- 
tion to the footwear is essential; and, if the individual wears a roomy enough 
boot, giving plenty of space to the big toe, it will afford relief. The sole 
should be stin, so as to prevent pressure on the end of great toe while walk- 
ing. In addition to this it is often necessary to place a pad or bar across the 
sole of the shoe- just behind the heads of tne metatarsals, so that the weight 
of the tr^ad comes not on the heads of the bones, but behind them. — Harold 
W. Jones, St. Louis. 

179. Bxperience with the Phelps Operation for Club Foot. By E. Muirhead 
Little. British Med. Jour., Oct. 17, 1903. 

Little has done the Phelps operation 27 times in the last twelve years ; 
and he divides his cases into two classes, as follows: — 

1. Those of such severe deformity that careful and persistent treatment 
by milder methods has failed to effect a cure, or cases of "necessity." 



326 ABSTRACTS. 

2. Those, chiefly in hospital practice, which, owing to poverty or indiffei^ 
ence, are neglected as regards aftei^treatment, and relapse again and again, 
or cases of "expediency." 

Bfr. Little makes a V-shaped incision, with its base toward the outer border 
of the foot, with its xp&i over the tuoerosity of the scaphoid. Everything 
beneath is then divided except vessels and nerves. Occasionally he divides 
the neck of the astn^us. The tendo Achillis is then cut, and the flap laid 
across the wound and held in place by one or two silkworm-gut sutures. The 
foot is put in a board rolint for a day or two, and then the f^ranulatine area 
is skin-grafted. After this it is put up in the best position obtamable in p&ster. 
Mr. Little thinks the skin graft a great advantage over the old Phelps opera- 
tion, and he believes also that the foot should not be put immediately into 
plaster, since a bulky dressing is then needed, which prevents a good hold 
being secured on the foot, and also because the hard blood clot later is apt 
to cause pain, and even doughs. 

The article is abundantly illustrated with photographs of Mr. Little's 
cases. He concludes: — 

1. That in selected cases Phelps operation is of great value, but that a 
skin flap should be made. 

2. That osteotomy is rarely necessary as a part of the operation. 

3. That the operation in young children is contrtundicated, because of the 
difficulty of predicting what the ultimate results of growth and pressure 
may be and tne danger of severe flat foot following. 

4. That, if for reasons of expediency cases must be operated on young, 
and flat foot result, the patient is far'better off than if he had relapsed or 
partly cured varus. — Harold W. Jones, St, Louis. 

x8o. The Radical Cure of Bunions. Am. Med., Jan. 1 6, 1904. 

Bunions, next to corns, are probably the most common of the various 
causes of foot discomfort; and in persons whose occupations require them to 
be constantly on their feet they may cause actual aisability. The term is 
generally used to denote a painful swelling which frequently g^ws over 
the inner aspect of the ball of tne great toe. In the first stage there is a partial 
outward dislocation of the great toe, the deviation from the middle line being 
caused almost always by fuilty-fitting shoes which are now commonly worn. 
Most shoes on sale, no matter how broad the toes and supposedly sensible 
they are, crowd the great toe outward and thus make the oase of the toe 
more prominent and subject to abnormal pressure. By placing the inner 
side of the foot of a healthy child against a straight edge it will be seen that 
the inner border of the foot forms fumost a straight line from the toe to the 
heel. Few modem shoes are made with a straight line from the heel to the 
toe, though there has been much improvement in footwear of recent years. 
The abnormal pressure over the base of the great toe forms a bursa, and fre- 
quently there is a chronic periostitis, which causes the head of the metatarsal 
bone to enlarge. Pressure on the bursa makes it sensitive and often intensely 
painful. Very few doctors are consulted for bunions, and it must be confesseii 
that this is partly because many do not imderstand their proper treatment. 
Indeed, the subject is given most inadequate attention in many of the most 
popular modem text-books on surgery. If physicians appreciated the im- 
portance of proper footwear, as emphasizea by Sampson in perhaps the 
most important paper (Am. Med., 1902, vol. iii. p. 105) which has appeared 
on this subject, they might do much to prevent numerous painful affections 
of the feet by using their influence to mtroduce proper footwear; and, if 
people were provided with suitable shoes from their earliest years, there 
would be no necessity further to discuss the treatment of bunions. Taken 
at an early stage, hallux valgus, which precedes the formation of bunion, 
may perhaps be partly correctea by apparatus; but toe posts, springs, ana 
levers which are used to prevent or correct such deformities are of use only 
when the condition has not passed the early stage. Freeland, in a recent 
monograph, believes that of tne numerous operations which have been intro- 



ABSTRACTS. 327 

duced to remove the boss of bone which gives rise to bunion none gives such 
uniformly good results as excision of the head of the first metatarsal bone. 
The relief from pain, restoration of fimction, and reduction of deformity 
which follow are striking. This method is also recommended bv Rose and 
Carless in the latest edition of their '' Manual of Sui^gery." While palliative 
or less radical measures may be tried and may give relief in many cases, 
we believe that excision gives far the more satisfactory results in the treat- 
ment of very bad cases of bimion. We are surprised that this method is 
not mentioned in several of our modem American text-books of surgery. 

i8z. Tarsal and TarsometatarBal Disease and its Treatment. Zeitschr, /. 
orth, Chir., 1903, xi. 
K. Hosebrock takes issue with all observers who ascribe every pain and 
other symptom of the foot to incipient or existing flat foot, even in cases 
where no flat foot or even where a springy foot exists. He sees in them an 
illness per se, a disease of the joints of the tarsus or tarsometatarsus, which 
is not m the slightest way connected with either chronic or inflammatory 
flat foot. They are usuaUy either of rheumatic or gouty origin, and are 
characterized chiefly by pain on pronation and supination of the foot and 
by stiffness of the affected joints. In the case of the tarsometatarsal affec- 
tion the characteristic symptoms are rigidity and stiffness during plantar 
flexion, and simultaneous inversion of the anterior part of the foot, corre- 
sponding to slight pronation. There is tenderness over the joints and over 
the ball of the great toe. The prognosis in the condition is good, the treat- 
ment consisting in massage, passive movements, and the wearing of suitable 
insoles. — Abst, Am, Med. 

i8a. Primary Actinomjwosis of the Bones of the Tarsus. Muen. med. 
Woch., Jan. 6, 1903. 
O. Bollinger discusses the position of the actinomyces among the fungi, 
the manner of cultivating them, and the routes by which they enter the 
organism to infect it, al»o the pathology of the disease. He then relates 
the case of a man of sixty-four, who at the age of eleven injured the dorsum 
of the left foot with an iron instrument. After several weeks of suppuration 
the wound healed, and he had no further trouble with it until he was sixty- 
one, when pain and swelling appeared. Later he was unable to walk. A di- 
agnosis of suppurative ostitis, possibly tuberculous, was made, and the foot 
amputated. An examination showed the bones riddled with actinomycotic 
sinuses and filled with fungi. It is possible that it was a recent cryptoge- 
netic iof ection, but it is much more likely that the infection occurred fifty- 
three years before, being latent all these years. — AbsL Am. Med. 

183. The Occurrence of the Os Trigonum in Man. By Nion. Deutach. 
milU. Zeit., 1903, p. 196. 

In 291 skiagraphs of the foot, 13 (4.4) showed the presence of the os trigo- 
num. This is of interest because of the possibility of mistaking it for a fract- 
ure. — A. H. Freiberg f Cincinnati. 

184. Genesis and Treatment of Hollow Foot. By Heusner. Von Lang- 
enbecl^8 Records, vol. 69, Nos. 1 & 2. 

A girl nineteen years old had an extreme double hollow foot. Within three 
mon^ the foot was given an almost normal form. This was brought about 
by means of the author's ring-shaped lever. Subsequent treatment in 
connection with massage and gymnastics was carried out bv means of a self- 
redressing apparatus. This consisted in broad straps of leather by means 
of which the oack of the foot could be pressed against a sole of iron. 



328 ABSTRACTS. 



RHEUMATISM AND RHEUMATOID AFFECTIONS. 

X85. The Formation of Loom Cartilages in the Knee Joint By E. A. Cod- 
man, M.D., Bofiton. BoaUm Af . dk S, Jour,, Oct. 15, 1903. 

The author recites a series of observations and expenments to show that 
the so-called "rice bodies/' or "joint mice/' found in tne knee joint are caused 
by the separation of small pieces of articular cartilage, usually from the 
internal condyle, which continue to live and acquire bony accretions after 
separation. 

lie was first attracted to this theory by noticing, in operations for removal 
of these bodies, a scar in the internal articular cartilage. Later he operated 
upon a case in which the loose body nearly fitted into a depression, or "bed/' 
in the internal cartilage. 

He exhibited a case from which he had removed four bodies, one of which 
was -still adherent, like a "trap-door," to its bed in the condyle, while an- 
other fitted its bed exactly. Some showed considerable accretion of bony 
substance, and were considlerably lar^per than those that did not. He thaws 
skiagrams of the bodies removed with others from other sources, to show 
the new bony accretions; also, a skiagram of the joint before operation, in 
which three of the four bodies can be seen. He tried experimentally, on the 
cadaver, to detach such bodies from the internal condvle, but found that 
a blow caused a depressed fracture of part of the cartilage with a piece of 
cancellous bone, but did not detach it. He thinks this separation persists, 
and the fragment is detached Latar by a second injury after necroeis or callus 
formation has occurred. 

He thinks the reason why the injury occurs more frequentlv to the internal 
condyle is because the external condyle is protected by tne patella when 
the knee is flexed. — John L. Porter, Chicago, 

x86. Contribution on Osteoarthritis Deformans. P r ogre ss in the Field of 
Roentgen Rays. By A. Koehler. 

X-rays are indispensable in studying osteoarthritis deformans, since b^ 
this method alone can we study the disease in its early stages. Before this 
discovery we had only an occasional chance to do this. 

The author considers the most probable cause of the disease to be a con- 
genital or acquired disease of the nervous system which inhibits more or less 
Its trophical influence. He supports this view by manv good pictures of 
the various phases of the disease. He considers that the intensity of the 
primary disease determines whether one or several joints are affected. It 
IS impossible to enter into the particulars of this valuable article, since it is 
necenary to follow the illustrations. — Abst, Archiv /. Orth,, i. 2. 

X87. Rheumatic Arthritis and Other Allied Joint Affections. Lancet, JbjiAO, 
1903, p. 102. 
J. Dreschfeld, at the meeting of the Manchester Medical Societ]^, said that 
most pathologists and clinicians were now agreed that rheumatic arthritis 
was an infectious disease, but the question miether it was due to a patho- 
^nic micro-organism or whether more than one micro-organism might give 
rise to the same sjnnptom-complex, or whether it was due to a non-specific 
micro-organism wmch only under certain hereditary or predisposing con- 
ditions became active, was stUl a disputed point. G. A. Wrignt spoke of 
the need for an entire revision of the nomenclature of joint disuses and the 
desirability of abolishing all names with rheumatism in them. J. Dixon 
Mann fully admitted the micro-organ ismal causation of acute rheumatism, 
but could not accept the view that streptococci which were capable of pro- 
ducing ordinary septictemia were the micro-organisms in question. — Abti, 
Am, Med. 



ABSTRACTS. 329 

x88. Articular Rheumatisin and Some Allied Conditions. Am, Jotar, Med. 
Sciences, March, 1903, p. 412. 
Alfred Stengel presented records of six cases, illustrating various t^pes 
of joint disease having a more or less superficial resemblance and requinng 
careful studv to determine the pathology and diagnosis. Three of the cases 
were typical mild acute articular rheumatism, with varying conditions. One 
case was that of chronic rheumatism. Two cases known variously as rheu- 
matoid arthritis, rheumatic gjout, gouty rheimiatism, deforming arthotis, 
arthritis deformans, osteoarthntis, Charcot's disease. The paper enters care- 
fully into the patholo^, and especially considers the clinical features, and 
is full of sound reasonmg from the aspect of the general medical practitioner, 
and wiU be read with benefit by all who have occasion to see jomts affected 
with the conditions described. — Ahst Am, Med. 

289. Farther Discussion of the Surgical Treatment of Arthritis DeformanSy 
especially of the Smaller Joints. By Dr. J. Elter, Rtetocker chirurg. 
KUnik. DetUach, Zeitachr, J. Chir., hon. 

The first part is a review of the surgical treatment in arthritis deformans 
of the mon-articular type. Large joints have been resected with favora- 
ble results, but the smaller ones have only seldom been operated on. 

In the next part the author reports five cases in which he himself operated 
on smaller joints for arthritis detormans. 

Case I. Tempero-maxillary joint. — Resection of articulation, which 
showed characteristic changes: namely, Absorption of cartilage, ebuma- 
tion, and proliferated edges. After three years patient had had no pain, 
and had good functional result. 

Case ir Metacarpo-carpal joint of thumb. — Opening the joint revealed 
a yellow exudate, a tnickened capsule, fibrillation of the cartilage, and prolif- 
erated margins. The capsule was extirpated, the articular facets cleaned, 
and the proliferated edges chiselled off. Result, pain gone, motion good, 
except slight stiffness in morning. 

Case III. Metatarso-phalangeal joint- of great toe. — ^The chief trouble 
was great pain. The toe was dorso-flexed. Operation showed villous de- 
generation of the 83movial and thickened joint edges, causing mechanical 
obstruction to motion. The edges were chiselled off and the capsule extir- 
pated. Result good and ankylosis in straight position. 

Case IV. Chopart's joint. — ^The operation was done for suppuration in a 
tendon sheath communicating with jomt, but characteristic changes of arthri- 
tis deformans were found. The anterior astragaloid facet was resected 
and the tendon sheath laid open. Result good, with limitation of motion. 

Case V. Astragalo-scaphoia joint. — Bad pain and difficult walking. The 
X-ray showed arthritis deformans. The scaphoid was excised. Result, 
improved. 

Finally, the writer reviews palliative measures and other operative pro- 
cedures. He concludes by saying spontaneous improvement nas been ob- 
served, but questions whether such improvement is possible in cases where 
actual absorption of cartilaee has already taken place, together with deformi- 
ties and proliferated joint eages. — Henry Feiee, Cleveland. 

190. The Pathology and Treatment of Rheumatoid Arthritis. By E. M. Mer- 
rins. New York Med, Jour., Sept. 19, 1903. 
E. M. Merrins says that the disease occurs in patients with an arthritic 
diathesis, or whose nervous system has been impaired by physical injury, 
shock, sorrow, or anxiety. Its history and the general clinical aspect of the 
disease point to some form of chronic poisoning as being most concerned in 
its production rather than to the direct action of a specific germ. This chronic 
poisoning depends on the elaboration in the system of certain toxins, which 
apparently may be the product of any general infection or local morbid 
condition. These toxins exert a peculiar and selective action upon the tissues 



330 ABSTRACTS. 

of the joints and nervous system concurrently, and so produce the charac- 
teristic nervous phenomena and arthritis of the disease. There is a small 
residue of cases closely resembling rheumatoid disease, if not identical with 
it^ which seem to depend wholly and directly upon some functional or organic 
disorder of the nervous system, as so far thev nave not been or perhaps can- 
not be traced to any source of infection. The treatment must be conducted 
on the following lines: 1. Discovery and removal of the source of toxic in- 
fection; 2. Elimination of poisons from the system; 3. The repair of ravages 
of disease; 4. The relief of pain. — Abst. Am. Med, 

xgi. The Diagnosis of Acute Tuberculous Rheumatism. 

The diagnosis of acute tuberculous rheumatism is often difficult, and one 
is frequently placed in a position of making a dis^ostic error. In children 
this is more likely to happen on account of the dSSculty experienced in ob- 
taining correct answers to questions. An osteomyelitis, especiallv when 
localized near the epiphyses and showing itself in several points at tne same 
time, may give rise to many mistakes; but under these circumstances one 
should take Into consideration the intensity of the general symptoms, the 
rise in temperature, the marked typhoid condition, and rely above all on the 
findings given by a minute examination of the skeleton. It is, however, 
with acute articiilar rheumatism that the acute tuberculous form is more 
frequently confounded, because in the latter affection its polvarticular mani- 
festations simulate the ordinary acute type, while clinically they closely 
imitate each other. The tuberculous form, however, differs by the' rapidity 
with which it becomes localized in a joint, by the absence of any effect from 
the administration of sodium salicylate or tne coal-tar products, and above 
all by its tendency to give rise to plastic products, often resulting in an- 
kylosis. A point to be noted in the differential diagnosis is the character 
of the pain. In the infectious pseudo-rheumatism, aue to Koch's bacillus, 
as in all forms of arthritis for tnat matter, the greatest pain will be found 
by exerting pressure over the joint itself; while in acute articular rheumatism 
the periarticular parts, tendon sheaths, periarticular serous bursas, artic- 
ular ligaments ana tendons, will give rise to the pain. It has been ]>ointed 
out by Las^gue that in acute articular rheumatism there is no intra-articular 
pain, but the fibrous tissue and bursas and serous coverings of the tendons 
are more involved than the synovial membrane of the joints. He gave as 
a proof of this the possibility 4>f giving passive motion to joints so afflicted 
without provoking suffering to the patient, if the latter could be made to 
relax the muscles ^oing to the joint thus immobilized. A differentiation 
with true acute articular rheumatism having been made, it is necessary, in 
order to complete the diagnosis, to look for the cause of the trouble, — a task 
often long and difficult. If, however, the patient has never been the victim 
of gonorrnoea or former puerperal infection, nor of any infectious process 
susceptible of producing joint manifestations, one should always think of 
tuberculosis, should the patient give an hereditary or peraoniQ history of 
tuberculosis or should he show lesions of a tuberculous nature, it is both 
logical and prudent to connect the joint affection with Koch's baciUus. 
Cytodiagnosis, peritoneal inoculation in the ^inea pi^ of the fluid obtained 
from the joints and cultures made from it, will result m settling a faltering 
diagnosis. — Am. Med. 

19a. Arthritis Deformans: The Report of a Series of xzo Cases from the 

Johns Hopkins Hospital. By Thomas McCrae, M.D., M.R.C.P. 

London. Jour. Am. Med. Aas'n, vol. xlii., January 2, 9, and 16, Nos. 

I, 2, and 3. 

McCrae describes the chaotic condition of terms, emphasizes the relative 

frequency of the disease, and urges the necessity of early diagnosis. He 

recognizes two types, the so-call^ osteoarthritic and the rheumatoid, and 

considers the question of there being different diseases as open. 

The general statistics of these 110 cases show the sexes about equally 



ABSTRACTS. 331 

divided. Ninety-six were native-bom, and the vast majority were engaged 
in indoor occupations; while a very small proportion were exposed to imfav- 
orable weather conditions. 

He divides the cases for clinical study into four classes: — 

1. Heberden's nodes. 

2. Polyarticular form (excluding spondylitis). 

3. Monarticular. 

4. Spondylitis. 

1. Heberden's nodes. He calls attention to the facts that (1) the accu- 
rate knowledge of the condition ia slight ; (2) they are rarely associated with 
serious dLsease in other joints; (3) they are of the osteoarthntic type, and yet 
sometimes seen with lesions in other joints of the rheumatoid type. 

2. Polyarticular forms. These comprise by far the greater number (02) 
of cases. He includes here the two cases of so-called ''Still's'' disease, which 
occurs in young subjects, is polyarticular, showing mainly periarticular 
changes and little bone involvement. In these periarticular cases the onset 
was gradual In 45, sudden in 31. The majority were polyarticular from the 
start. The attacks were of two main characters, — slow' progressive in 44, 
repeated acute in 29. Twelve showed characteristics of both. Illustrative 
cases of both are given. He then considers the svmptoms in detail, taking 
up the special joints, of which the most frequently mvolved are the knees 
and shoulders. 

In the differential dia^osis from acute rheumatism he considers the poly- 
arthritis, the slight rise m temperature, the rather rapid pulse, the atrophy, 
the slow progression, and the negative action of salicylates as striking feat- 
ures. The urine was usually normal, glandular enlargement common, splenic 
enlargement rare, subcutaneous fibrous nodules in 7 out of 110. The Iblood 
shows a red count, and haemoglobin higher than the frequent pallor su^ests. 

The pathology of the condition is said to be stiU uncertain. The view of 
an infective origin with a secondary toxsmia explaining some of the nervous 
symptoms is favored. 

The treatment. In the acute attacks palliative; after the acute attack 

general tonic, with much out-of-door life and much attention to nutrition, 
edicinal baths are often harmful. 

McCrae urges massage of the joints in the early stages, and speaks favor- 
ably of hot air in administration of 20-30 minutes at 350^ F. Use of the 
joints after the acute attack is encouraged. Of the drugs he commends the 
use of iodide of iron and arsenic. 

In the line of surgical treatment, tenotomies and forcible straightening 
under an amesthetic are advised in the presence of obstinate contractures, 
while excisions are considered justifiable in certain cases. • 

The prognosis should be guarded, and is usually rather gloomy. 

3. Monarticular form. The author considers that more of the cases of 
chronic articular rheumatism should be classed here, and also the t3rpe morbus 
coxse senilis. 

The treatment he considers palliative onlv. 

4. Spondylitis. This group McCrae considers chiefly of the osteoarthritic 
type. It is much more common among males. The frequent onset in early 
adult life is also striking. The temperature is usually slightly raised, the 
blood is negative. 

Pathologically, he recognizes the new bony deposit occurring frequently 
along the anterior aspects of the vertebral Sodies and often involving the 
intervertebral disks. liateral curvature results, if the disease is more on 
one side than the other. The conunon leg pain is due to nerve root pressure 
from the new bony deposit. 

The diagnosis is not difficult with a knowledge of the condition. The 
credit of drawing attention to these conditions he attributes to Dr. J. E. 
<joldthwait, of Boston. He recognizes the fact that many cases of so-called 
sciatica are due to this condition. 

The mainstay of the treatment is complete rest, accompanied by a stiff 



332 ABSTRACTS. 

jacket; plaster at first implied with patient standing in as correct position 
as possible without the use of force; later a leather jacket, wluai the devia- 
tions have been corrected, perhaps followed by a lighter support until the 
process is at a standstill. He gives the following conclusions: — 

1. "The frequencv of the occurrence of acute polvarthritis in arthritis 
deformans and the danger of mistaking this for acute rheumatism." 

2. "The importance of recognition of the spinal forms of the disease, e»- 
peciaUy the local involvement." 

3. "That in arthritis deformans we have an obscure disease of considerable 
frequency worthy of study, especially from the etiological .aspect." — R. B. 
Osgood, Boston, 

PARALYSIS. 

igs. The Correction of Deformities following Anterior Poliomyelitis by 
Subperiosteal ImplanUtion of Tendons of Unaffected Muscles. By 
James T. Watkins, San Francisco. California Stale Jour, of Med., Sep- 
tember, 1903. 

After briefly reviewing the pathology of infantile paralysis, Watkins says 
that where secondary deformities are present the orthopedic problem is two- 
fold: first, the correction of the deformity; second, the restitution of function. 
He discusses the earlier methods of treatment; the application of portable 
apparatus with no attempt to correct the deformity; the forcible "remodel- 
ling" method, combined with division of such structures as coidd not be 
stretched, and followed by functional use of the limb, which was hdd in posi- 
tion by plaster of Paris and subseouently by sheath-splints. Arthrodesis 
is advocated in selected cases. He aescribes at length tne technique of the 
tendon-to-tendon suture as first employed by NicoL^loni and afterwards ad- 
vocated bv Vulpius and others, and recommends buttonholing one tendon 
into the other, and the cross coaptation suture employed by Vulpius. 

The method is subjected to a critical analysis The reports of good results, 
with which the later orthopedic literature teems, are discoimted, because 
of the indefinite tankage m which these reports are framed. "Whether 
'a good result,' 'a satisfactory result,' signifies that there is no return of the 
deformity, or that there is a complete or almost complete restitution of fimc- 
tion, the reports do not show." He believes that, if cases other than those 
due to poliomyelitis were excluded from the reports, and if a longer period 
of time were permitted to elapse between the operation and the reports of 
the operation, a very much smaller percentage of good results would be re- 
corded. Causes of fulure are classed as function^, technical, and patho- 
logical. In the first group, failure may be due to employing too weak a 
muscle to do the work of a strong one, or perhaps to grafting a paralysed 
muscle to one of a widely different or antagonistic function. Tecnnic^ defects 
are errors in sewing, failure to obtain a sufficient tension, and so attaching the 
tendons that the pull of the active muscle is not exerted in the direction of 
its muscular contraction. The pathological cause of fsdlure is seen in the 
fact that through destruction of the trophic centres in the cord an atrophy 
has resulted which is out of proportion to the atrophy following disuse alone. 
Consequently, except in selected cases, the tendon of the paralvzed muscle 
stretches between its insertion and its attachment to the healthy tendon. 
For these reasons the result must in most cases be transitory, and necessitate 
the wearing of apparatus. 

Watkins advocates the method of periosteal or subperiosteal implantar 
tion as performed by Lange. It consists in freeing the whole or part of a 
healthy tendon from its insertion, and attaching it to that bony pomt where 
it will obtain the best leverage in combating the tendency to deiormity and 
to restoring fimction. The advantages of tnis method are the employment 
of healthy tendon and the freedom permitted in choosing the site for the 
attachment of the new muscle. The completeness of the result will depend 



ABSTRACTS. 333 

upon the tension under which the new muscle shall begin to contract. The 
technique of the operation is minutely described and illustrated by seven 



/^hen a result has held its own during nine months of functional use, it 
may be safely classed as permanent. 

A report is appended of an independent examination made by Watkins 
upon SIX of Lange's cases eighteen months to two years after they had been 
operated upon. 

X94. A Method of Treating by Operation Paralysis of tlie Upper Root of 
the Brachial Plexus. By A. H. Tubby. British Med. Jour., Oct. 17, 
1903. 
The chief muscles affected in this t)rpe of paralysis (the Erb-Duchenne 
type) are the deltoid, infranspinatus, biceps, brachialis anticus, and supinator 
longus. The patient is unable to flex the elbow and cannot abduct the 
Moulder. So far as Mr. Tubby's knowledge goes, no one has attempted 
nerve grafting to replace the cfamaged root; and ne thinks that the com- 
plexity of the problem is so Ereat that it is doubtful if we are to get any re- 
lief from this procedure. In nis opinion it is best, therefore, to utilize what 
is left of the remaining healthy muscles of the upper extremity. The resto- 
ration of power of flexion to the elbow is the easier, and that of abduction of 
the shoulder the more difHcult, of the two problems. Mr. Tubby uses the 
triceps muscle in the following way: An incision 4 to 6 inches long is made 
from the middle of the back of the upper arm downwards and forwards to 
the front of the elbow and following the course of the musculo-spiral groove. 
The musculo-spiral nerve is drawn one side. The outer part of the triceps 
is detached low down near the olecranon until a strip 4 inches long is ob- 
tained. This is inserted into the biceps through a slit made 2 inches above 
its insertion, and firmly pleated in place while the elbow is held in the flexed 
position. In two cases where the writer did this operation, voluntary mo- 
tion returned in from four to six weeks. He thinks it better to treat the 
elbow first, and later operate for the relief of the paralvzed deltoid. The 
steps of the operation which Mr. Tubby has performed (muscle n-afting) 
are as follows: The incision commences 1 inch below the middle of the clav- 
icle, passes outward to the tip of the acromion, and then downward for 
3 incnes. A second incision is made from the tip of the acromion upwards 
for 3 inches or so along the margin of the trapezius. Flaps are reflected, 
and the portion of the pectoralis major arising from the clavicle is followea 
to its insertion into the humerus and detached. The insertion of the trapezius 
is then separated from the clavicle. The clavicular portion of the pectoralis 
major, now almost a separated muscle, is brought upward so as to lie over 
the acromion process and tail downwani towarof the msertion of the deltoid. 
The portion of the trapezius detached from the clavicle is now inserted into 
the upper part of the pectoralis, so that a new conjoined muscle is formed 
of trapezius and pectoralis. If the tongue of muscle is long enough, it is well 
to turn up a large piece of periosteum near the deltoid insertion, and attach 
it here : but otherwise it is inserted directly into the deltoid near its inser- 
tion, in the first case which Mr. Tubby operated upon he used the pectoralis 
major only, the result being that considerable power of abduction of the 
shoulder was regained. In the second case the trapezius was used also, 
and the result here promises to be much better. The writer makes the point, 
also, that after muscle grafting operations the grafted muscle must never 
be put on the stretch for at least a month, and should be very gradually al- 
lowed to attempt to perform its full function. — Harold W, Jones, St. Umis, 

195. Modem Methods in the Surgery of Paralsrses, with Special Reference to 
Muscle Qralting, Tendon Transplantation, and Arthrodesis. B^ A. H. 
Tubby, M.S. Lond., F.R.C.S. Eng., and Robert Jones, F.R.CS.E. 
In the "Surj^ of Paralyses," by Mr. A. H. Tubby and Mr. Robert Jones, 

we have descnptions of the most successful methods employed in this most 



334 ABSTRACTS. 

modem domain of surgery. The authors speak from large personal experi- 
ence, and are broadly conversant with the best German and American work. 
Many of the measures advocated are ori^al, and all are illustrated by care- 
fully recorded cases which have been satisfactorily treated by these methods. 
In the three sections of the work are considered: — 

1. Infantile paralysis, or acute anterior poliomvelitis. 

2. Infantile spastic paralysis, or cerebral panuysis of children. 

3. Paralysis and deformities arising from injuries and diseases of nerves 
and some degenerations of the spinal cord. 

The first section deals with infantile paralysis etiolopcally, pathologically, 
and in detail of lesion. The reader is struck with the simplicity and economy 
of much of the apparatus advised, while both in the mecnaniciBtl and surgical 
treatment a most strong element of "common sense" predominates. For 
instance, the importance of placing the weakened muscles under mechanically 
favorable conditions is emphasiz^ as the "dominant note in the long list 
of paralytic deformities." The methods of muscle grafting and tendon trans- 
plantation are given in great detail, with descriptions and illustrations of 
indications and operations. 

The second section is most interesting to any one who has seen the really 
remarkable results of Mr. Jones's cases of spastic paraplegia treated by cour- 
ageous surgical measures. The fact that many of these unfortunates now 
walk comfortablv without distressing spasticity and with their mental hori- 
zons much broadened is due to him. 

The last section comprises many of the rarer forms of paralysis, from the 
various toxsmias and traumata^ Many of these conditions the authors 
frankly state are not amenable to surgical treatment. 

The book supplies a distinct want in English orthopedic literature, and 
indicates original and successful surgical methods of treatment in many cases 
which have long been considered as belonging exclusively to the instrument 
makers or the neurologists. — R. B. Osgood, Boston. 

TENDONS AND I^USCLES. 

Z96. The Results of Extirpation in Hygroma of Tendon Sheaths of thm 
Hand. By Z6ppritz. Beitr. z. Jdin, Chir., Bd. XXIX. Heft 3. 
With the acceptance of the tuberculous natiire of these cases, exturpation 
has become the rational method of treatment in place of simple incision or 
curettage of the sheath. The justification of this treatment lies m the paucity 
of recurrences after it. Thirty-five cases so treated are reported. Thirty- 
one have been followed up. Of 33 hands thus operated upon, 25 have re- 
mained perfectly well. In more than half of the cases the function of the 
hand was perfectly restored. Since the cases were for the most part well 
advanced before operation, the author considers the results very satisfactory. 
A, H. Freiberg, Cincinnati. 

197. A Case of Progressive Ossiflcating Myositis. By E. Soncini. Arch, di 
Ortop., 1903, XX. 2. 
A girl of four years and eleven months was admitted July 25, 1902. A 
sister had died of menin^tis. Two months before admission a tumefaction 
was noticed under the chm, then in various places on the neck and armpits. 
When admitted, the movements of the head were very limited. The treat- 
ment was mercurial and iodo-ferruginous frictions with some improvement, 
but some of the symptoms persisted. Five months after, the head and neck 
remained in rij^id flexion. Taken home by parents Jan. 20, 1903. Seemed 
near death. The local conditions had not changed. The above-mentioned 
treatment, supplemented by warm baths, seemed to have no appreciable 
efifect. 



VoLUMK I. MAY, 1904. Number 4. 

"The American Journal of 
Orthopedic Surgery 



A UNIQUE CASE OF CONGENITAL LUXATION OF THE 

ANKLE. 

ALBERT H. FREIBERG, M.D., CINCINNATI, OHIO. 

In all of the reported cases which I have been able to find, 
congenital luxation of the ankle has been associated with defect 
of the fibula. These cases have been divided by Hoffa into 
two classes. In the one the defect of the fibula has been asso- 
ciated with angular deformity of the tibia and defective develop- 
ment of the foot; in the other the foot has been of normal shape, 
but the outward deviation of the foot upon the leg has been 
ascribable to the imperfect development of the external mal- 
leolus, depriving the astragalar mortise of its outer part, and to 
the obliquity of the articular surface of the tibia. The case 
which is herewith reported belongs in the second class for the 
reason that the obliquity of the joint line and normal condi- 
tion of foot and toes are evident. It would appear to be of 
especial interest, however, because the fibula is present through- 
out its course, being possibly thicker than normal, and because 
it seems possible to draw rather definite conclusions from it 
regarding the etiology of this whole group of cases. 

The patient, a girl of twenty-four months, is the daughter 
of a baker, and was brought by her father to the dispensary 
of the Medical College of Ohio. The deformity of the left ankle 
had been noticed from birth; and its correction had been at- 
tempted by desultory courses of manipulation and massage. 

Presented at the Seventeenth Annual Meet hi? of the Association, Washin^on, 
D.Cm May 11-14, 1903. 



336 



CONGENITAL LUXATION OF THE ANKLE. 



but without effect. From the first, attempts at walking were 
attended with great difficulty, but the child has learned to walk 
with a peculiar limp. Upon walking a short distance, the child 
complains of fatigue and finally of pain. There have been no 
congenital malformations in other members of the family (four 
other children). The pregnancy and labor of the mother were 





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Fio. 1. Congenital dislocation of the ankle. 
I'sed by permis.sion of the *' Annals of Sun/ery.*' 

absolutely uncomplicated. The father acknowledged having 
had a venereal sore many years ago, for which he was treated 
and which has been followed by no symptoms of constitutional 
lues. His other children, according to his statement, have 
shown no signs of this disease. The mother never miscarried, 
and all of her children are living. 

The child has always been in good health. There have been 



ALBERT H. FREIBERG. 337 

none of the symptoms of rickets. There is no rosary, and the 
epiphyses of the other long bones are of normal size. The head 
is of normal shape. The gait is a peculiar limp, showing great 
weakness in the left limb; and the pelvis is seen to descend with 
the application of the left foot. The whole plantar surface is 
brought into contact with the ground. The photograph shows 
the outward displacement of the foot upon the leg when weight 
is borne, but not nearly to the true extent. The child had to 
be held by the father for the picture, but kept the knees some- 
what flexed. The feet are both very flat, but are not everted 
in walking or standing. Even in recumbency the left foot 
had its axis in a plane decidedly lateral to that of the leg. The 
internal malleolus appeal's prominently, and the external also 
can be seen. They are both felt to be enlarged, but especially 
the external, which lies in a plane decidedly above that of the 
other. Passive motion of the ankle shows the joint line to be 
oblique from without inwards and downwards. Almost the 
full normal range of motion is present. The internal contour 
of the limb is quite straight: the external presents a marked 
indentation above the ankle. There was no sore or dimple 
of the skin at this place. The fibula can be felt throughout 
its length. The feet are of equal size, and present no abnor- 
mality of development. The legs are of equal length. The child 
is otherwise perfectly developed and healthy. 

The child was so unruly that the radiograph was made with 
difficulty. It was, however, sufficiently successful to show 
the conditions satisfactorily. It is at once seen that the fibula 
is present in its entire length, but that its shaft is greatly curved 
inw^ards, diminishing greatly the width of the interosseous 
space. The bone appears thick in comparison with the tibia. 
The diameter of the latter on the radiograph is 12.0 mm. at 
the middle, while that of the fibula is 8.0 mm. at a correspond- 
ing point. It is in the ankle joint, however, that the most 
interesting condition is found. Instead of being distinctly 
lower than the inferior tibial epiphysis, that of the fibula is 
higher. The joint line is at an angle of 75° with the axis of the 
leg, slanting from without inwards and downwards. On the 



338 COXGENITAL LUXATION OF TOE ANKLE. 




Fio. 2. Congenital dislocation of the ankle. 
Used by permission of the '* Annals of Surgery." 



ALBERT H. FREIBERG. 339 

tracing made over the negative, therefore representing the 
limb in recumbency, the axis of the leg falls to the inner side 
of the astragalus altogether. It appears to me perfectly justi* 
fiable, on this accoimt, to consider this a congenital dislocation 
of the ankle joint. 

It was proposed to do osteotomy of the fibula in the hope of 
bringing down the external malleolus, with possibly the same 
operation upon the tibia in order to correct the obliquity of the 
joint line. All operative interference was, however, declined; 
and the child disappeared from view. 

As far as I have been able to ascertain, the case is unique, 
and its practical interest is therefore; not great. In endeavor- 
ing to account for its production, it' appeared to me to stand 
in an interesting etiological relation to the cases of defective 
fibula. The most commonly accepted view of their causation 
is that of Sperling,* which assimies the pressure of a too narrow 
amnion early in the embryonal period. In the present instance 
it would appear that the curvature of the fibula must have 
been produced by some such pressure, — pressure great enough 
to simply bend the developing fibula, but not enough to inter- 
fere with its further development. Whether the joint line was 
oblique at birth it is impossible to say. This may have de- 
veloped in consequence of the abnormal function of the joint 
during the second year of life. The same may be said of the 
thickness of the fibula. In weight-bearing the astragalus was 
imder the lower fibular epiphysis, and it is therefore probable 
that the fibula transmitted considerable stress to the foot. 

In all of its physical characters, it seems to me, this case would 
correspond to an incomplete form of the so-called "Volkmann's 
Congenital Ankle Deformity," m so far as the fibula has its 
bony structure intact.f It is furthermore almost self-evident 
to me that the curvature of the fibula against the straight tibia 
could have been brought about only by pressure upon it against 
the tibia. In this far, this case seems to corroborate the theory 
of amniotic pressure in the production of defective fibtilse and 
the deformities thereupon consequent. 

* Sperling, Zeitschr. f. Oeburtah. u. Oynakol, 1892. 
t Haudek, Zekschr. /. oHh. Chir., Bd. LV. p. 338. 



II. 

A PRELIMINARY STUDY OF FUNNEL-FRONT. 

T. C. BALDWIN, M.D., SALT LAKE CITY, UTAH. 

That the deformity known as Funnel-breast is not so rare 
an affection as is usually supposed, I am very well satisfied. 

This affection, which is now usually known as Funnel-breast 
of Ebstein, and which has since been called Funnel-chest by 
some one, whose name I do not now remember, has been rec- 
ognized and described by a number of writers, particularly 
in England as well as in Germany, long before Ebstein wrote 
on the subject. His articles perhaps attracted more atten- 
tion than any of the preceding articles; and he was the first, 
80 far as I am able to learn, to give a particular name to the 
deformity. Others had written on the subject, describing the 
condition as a rare deformity of the breast-basket, and also 
under other names, all of which I think are more or less Incor- 
rect. It is hard to give the condition a name that will correctly 
describe it. 

But "deformity of the breast-basket," or "funnel-breast," or 
"funnel-chest," which Professor 0. L. Schmidt, of Chicago, in 
a letter to me on the subject says he thinks is more correct, all 
fail to more than partially describe the location of the deformity 
at the point where it is usually described as existing, although 
the range of location has been extended to take in much more 
than it seems was at first intended when the name "funnel- 
breast" was first given to the condition. 

This, I think, is right; for funnel-breast, if this name be 
adopted for the deformity, or funnel-front, — ^which I shall pro- 
pose as broader and allowing other portions of the anterior 
surface of the body to be included where a depression exists, — 
takes in more than the breast of the one affected. 

The funnel-breast of Ebstein was supposed to describe a 
depression including the lower end of the sternum, or xiphoid 



T. C. BALDWIN. 341 

cartilage, and the upper portion of the anterior abdominal 
wall lying between the cartilages of the lower ribs; but in the 
descriptions of the cases which I have found described under 
this head there are some which include much more than what 
is embraced in the boundaries which I have mentioned. This 
being the case, the name "fimnel-front," although hardly mak- 
ing the location definite enough, has seemed to me to be more 
nearly correct, because, besides including the anterior chest 
walls, or any portion of them that might show a depression of 
this character, it also includes the anterior abdominal wall, 
which forms a large part of the funnel as described \mder the 
term "funnel-breast." 

It seems that Ebstein in 1882 first called general attention 
to this deformity; and Dr. Hermann Goesche in 1895, in an 
Inaugural Dissertation, gives a very exhaustive review of what 
he supposes to be all the cases — twenty-four in number — which 
have been published up to that time, to which he adds the his- 
tory of six others, and to him I am indebted for the informa- 
tion in regard to these cases which would have been otherwise 
inaccessible. His cases, however, only cover those mentioned 
in the French and German literature, while a number of cases 
published in the English language are not mentioned. Such 
of these cases as I have been able to find I shall briefly men- 
tion; for the description corresponds to those described by Eb- 
stein and other German writers, and the condition is attributed 
to the same causes which some of the German writers have 
mentioned. 

Just here I may say that I doubt the correctness of the con- 
clusions as the cause in most of the cases I have seen mentioned 
by different authors. 

In order that we may study the different theories of cause 
of this deformity, I shall briefly mention a number of cases 
reported by the French and German writers, and for this pur- 
pose shall have to draw my information from Dr. Goesche's 
thesis, and then shall refer to those cases described by English 
authors and some in this coimtry, as well as four cases of my 
own which I shall very briefly mention, leaving a more complete 



842 A PRELIMINARY STUDY OF FUNNEL-FRONT. 

description for some future time when I shall have photographs 
and, if possible, skiagraphs. 

Nearly fifty years before Ebstein's paper Dr. John A. Ingels, 
of Paris, Ky., in a paper published in the Transylvania Journal, 
vol. vii., 1834, pp. 488-492, describes a case which, I think, 
might be truly called a double funnel-breast. 

A negro child belonging to Dr. Robert Taliaferro showed 
at birth a slight deformity. This increased imtil at the age of 
eighteen months the child died, death seeming to take place 
from suffocation. A post-mortem was held which the doctor 
describes in the following words : — 

The peculiarity of the case consisted mainly in an apparent effort 
on the part of nature to separate the cavity of the chest into two apart- 
ments, an anterior and a posterior. This was measurably accomplished 
by a very extensive incurvation of the nine or ten superior ribs on each 
side, so that at the distance of about one-third of their length from the 
sternal ends (the point of greatest indentation) their internal surfaces 
were very considerably approximated. But the division' was rendered 
much more complete by large cartilaginous tubercles of a semi-spherical 
form, one of which was based upon the point of the internal convexity 
of each curved rib. 

These tubercles were ranged in vertical rows, one on each side, and 
equi-distant from the sternum. 

They presented a singular and beautiful appearance; and, when dis- 
covered, the case assumed a new and more interesting character. 

The heart presented itself immediately to view when the sternum 
was elevated. It occupied the anterior chamber to the exclusion of the 
lungs. These, being thrown into the posterior, were not brought into 
view until the heart was partially removed and the approximated ribe 
forced wider apart. 

In 1840, in an article published in the London Lancet, vol. 
ii. pp. 44-46, George A. Rees, M.R.C.S., mentions a case with 
depression on sides of sternum, as described in his article ia 
the Medical Gazette of Jan. 12, 1839, and shown to the London 
Medical Society Feb. 12, 1839. 

While mentioning faulty positions in holding the child and 
compression of the chest, he believes that the cause of the de- 
formity is disease of the lungs, not allowing expansion. He 



T. C. BALDWIN. 343 

writes of the same subject in the Lancet in 1847^ and again in 
1850. 

In 1857 Dr. Glover in London Lancet^ vol. i. p. 263, men- 
tions the case of a male eighteen years old, with great depres- 
sion or absence of the ensiform cartilage. This depression was 
first noticed to begin when thirteen or fourteen years of age, 
gradually increasing. 

He is an imbecile, but not altogether without intellect. He 
has no pain and no other abnormality except some lateral 
curvature. No cause is known. 

In 1872 Dr. C. Theodore Williams in the Transactions of the 
Pathological Society of London, vol. xxiii. pp. 50-52, describes 
the case of a patient, age seventeen, as follows: — 

On examination I found the chest remarkably distorted, the lower 
half of the sternum and the adjoining cartilages being so depressed as 
to form a hole an inch and a quarter in depth, and large enough to con- 
tain the greater part of one's fist. 

The depression begins at the level of the third costo-sternal articula- 
tion, and ends with the ensiform cartilage. 

The chest is generally somewhat flattened and the shoulders thrown 
forward, and there is slight lateral curvature to the right. 

Antero-posterior measurement: — 

At level of mammse 6} inches. 

At ensiform cartilage 4} " 

Mother, father, and one brother had same hole in their chests. No 
others affected. This case was born with the depression, but at two years 
had whooping-cough, and since that time the depression has increased, 
and his breathing is interfered with. 

During the discussion of this case Dr. C. J. B. Williams men- 
tioned the case of a captain in the navy with a depression of the 
sternum so deep that it held a pint of water as he lay on his back. 

At advanced age he suffered from increasing embarrassment 
in breathing and circulation, and ultimately became dropsical 
from this cause. 

In 1886 Mr. B. Blower in the Liverpool MediahChirurgi- 
cal Journal, vol. vi. p. 470, describes the case of a male, age 
twenty-one, as follows: — 



344 A PRELIMINARY STUDY OF FUNNEL-FRONT. 

Approximation of anterior and posterior chest walls in the middle line. 

The second piece of the sternum is bent at an angle about the centre, 
apex of angle pointing backwards, forming cup-shaped depression hold- 
ing ten ounces when lying on his back. There is a lateral and an antero- 
posterior curvature forwards of the spine. 

Antero-posterior dimensions about three inches. Antero-posterior 
and median mediastina must be almost, if not entirely, obliterated. 
I have no doubt that rickets was the original cause of this deformity. 

In 1892 Professor Dr. M. Bernhardt, in Deutsch. Arch. /. 
klin. Med., vol. xlix. p. 604, mentions a case of depression 
at xiphoid. In 1889 Professor 0. L. Schmidt, in a paper read 
before the Chicago Medical Society and published in Medicine 
in May, 1895, p. 79, describes a case of funnel-breast in a man 
thirty years old. This man, up to the age of twenty-two, had 
never been sick, but now begins to suffer with marked gen- 
eral weakness and pains in the chest, particularly in the back. 
After about one year a cough shows itself. This condition 
continues for two years, gradually getting worse. During this 
time the attention is attracted to a gradual sinking in of the 
lower end of the breast-bone. After six years he has grown 
so much worse that he is entirely disabled. By this time the 
depression has reached a depth of 5^ centimetres, is to the right 
of the mesial line, and is accompanied by considerable irregu- 
larity of each lateral half of the thorax. There is a well-marked 
scoliosis. 

In both lungs there are inflammatory conditions of the bronchi, 
and in the lower posterior part of the right limg there is a large 
cavity. 

The existence of a bronchiectasis with a large cavity is es- 
tablished. 

Dr. Schmidt excludes this as a possible cause, and seems to 
incline to the belief that the deformity may be due to an osteo- 
malacial weakening of the bony and cartilaginous frame of the 
chest; and, as the lower end of the sternum moves, he believes 
that the end of the bone is fixed by some possible adhesions 
or that the fasciculus of diaphragm attached to it produced 
this action. This may possibly have played an important part 



T. C. BALDWIN. 345 

in the formation of the depression after the sternum began to 
weaken. 

These with the cases reviewed by Dr. Goesche and one or 
two others to which I do not now have access are all that I 
have been able to find on record; and the causes assigned for the 
condition, where any cause is mentioned, are ahnost as numer- 
ous as the cases. 

I shall now briefly look at the causes mentioned by the au- 
thors and reviewed in Dr. Goesche's paper, and then after a 
very brief mention of my own cases will compare the causes 
assigned, and see if we can reasonably accept any of them. 

Without attempting to review each case reported, I shall 
briefly mention those cases in which there were points of in- 
terest besides the funnel-breast. 

Eggel in his case says it cannot with certainty be shown 
that there was rickets. 

Fliesch reports a case at age of fourteen in which there was 
a high breast at first, and afterwards developed funnel-breast 
and scoliosis. 

Zukerkandl reports a case which, besides funnel-breast, has 
a kyphosis. 

Ebstein reports a case which in second year had inflamma- 
tion of brain, since which a paralysis of both limbs exists, and 
both are atrophied and both have contraction of knee. The 
left limb is in position of equino-varus, and the right in that 
of valgus. The second and third toes o( both feet have dis- 
appeared, and he has also a right-handed scoliosis. 

Graeflfner reports the case of a man eighteen years old whose 
mother states that during the last months of pregnancy she 
slipped and fell, striking the abdomen on a sharp-edged mile- 
stone with great force. Several days after delivery of the 
child she noticed in the cardiac region a striking deepening of 
the breast wall. With advancing growth the dimensions of 
this depression have constantly increased. The right side of 
the breast lags behind in respiration. The vertebral column 
runs spirally. 

Muhlhauser reports a case in a male forty-two years old. 



346 A PRELIMINARY STUDY OF FUNNEL-FRONT. 

In third year had rickets. The breast-bone with the ribs and 
collar-bones look as if they were pressed in by force in the form 
of a funnel, so that the outer dimensions from the breast-bone 
to the spinous processes amoimts to only three inches. 

Kiindmuller reports a case in a boy eleven years old. A 
small depression might have existed at birth. The vertebral 
column is scoliotic, and on both sides there is a genu valgum. 

He also reports a case of a man nineteen years old with fmmel- 
breast and dorsal scoliosis, whose father also has fimnel-breast. 

Vetlesen reports a case in a boy seven years old, who was 
born asphyxiated, on accoimt of which the midwife used pressure 
for a considerable time over the chest wall. 

Klemperer reports the case of two brothers, ages nineteen 
and twenty-three, whose mother, grandmother, and great- 
grandmother were all afflicted with this malformation. 

These brothers possess peculiarly formed crania, with flat, 
short foreheads. 

Grunenthal reports a case of a girl of seventeen years with 
depression that was noticed inmiediately after birth, and who 
also has scoliosis. The left arm and leg are weak and atrophied 
and shorter than the right. He also reports the case of a girl 
seventeen years old, a cousin of the last mentioned, who has 
three sisters with malformations, and one brother had funnel- 
breast. The right extremities are weak and atrophied, and 
have not developed as the left have. She has a kyphosis, and 
also a scoliosis with double club-feet. 

He reports the case of a sister of the above who has fmmel- 
breast and scoliosis with weak, h3rperextended joints. 

Dr. Goesche reports some other cases of funnel-breast with 
associated deformities. I shall now describe my own cases 
as briefly as possible. 

Case 1. — ^An eighteen-year-old ^rl has a depression of the 
ensiform cartilage and surroimding tissues, and, so far as I can 
learn, it is congenital; but it was not noticed, I think, imtil I 
was examining her for a slight scoliosis which has developed in 
the last two or three years. A younger sister has a consider- 
able lumbar scoliosis. 



T. C. BALDWIN. 347 

Case 2. — A boy nine years old has a marked depression of 
the ensiform cartilage, amounting to about 5 centimetres in 
depth. Six other children in the same family, also the father and 
mother, are healthy. Up to the age of four years this boy was 
well and strong. At this time he had rheumatism, and after 
this the depression began to show, and has increased until now 
it is quite large. The abdominal walls are flabby, allowing the 
abdomen to protrude markedly. His feet are in the condition 
of slight valgus. 

Case 3. — A two-year-old child has a depression to the left of 
the sternum, just over the apex of the heart. This is about the 
size of a half-egg, spht lengthwise. She also has a right-sided 
congenital dislocation of the hip. 

Case 4. — A five-year-old boy has a similar depression to the 
last one described, but has no other malformation. 

Whether these last two cases should be included as examples 
of funnel-front is a question ; and still I think they may, as the 
location of this trouble is not always just the same. 

Now as to the cause, I can only mention a number, and pass 
them hurriedly. Atmospheric pressure, which has been men- 
tioned as one cause, I do not believe has any influence what- 
ever in producing this deformity. 

A fall on a mile-stone, as mentioned in one case, I think, is 
an impossible cause; for I do not believe a child is ever in a 
hyperextended position in idero, with the chest wall pressing 
against the anterior abdominal wall of the mother, to receive 
a blow of this kind. Neither do I believe that prolonged pressure 
to resuscitate an asphyxiated child would produce any such 
condition. Neither do I believe that a fall in an epileptic 
attack would produce it. 

That intrauterine pressure may account for some congenital 
cases such as these last two I have mentioned, I think is pos- 
sible, as I believe it may account for some such conditions as 
congenital scoliosis. This may be caused by lack of amniotic 
fluid and too limited motion of the limbs. 

The mother of the last boy mentioned tells me she was very 
small during her pregnancy and had very little water. 

That a local arthritis deformans might follow an attack of 



348 A PRELIMINARY STUDY OF FUNNEL -FRONT. 

rheumatism and produce a condition of this kind might be 
possible. But these are merely suggestions. 

In acquired cases I believe the suggestion of Dr. Schmidt 
in regard to his case, that it might be due to an osteomalacia, 
is very likely correct. And that this same disease may mani- 
fest itself locally, and produce this deformity even in children, 
I believe is possible; for, while osteomalacia is a disease usually 
of adult life, we do have an infantile osteomalacia as well as 
the same disease in vtero. 

This or rickets, I believe, is the most plausible solution of 
the cause. Added to this, we may have a partial paralysis 
of the abdominal muscles, as we do of the leg muscles in cases 
of congenital club-foot and of the back muscles in scoliosis. 
It seems to me the strong contraction of that portion of the 
diaphragm attached to the lower end of the sternum, together 
with the triangularis sterni drawing the lower end of the sternum 
backwards with a relaxed condition of the recti, might encour- 
age a depression of this kind, which, once begun, would nat- 
urally increase. 

This might be a cause for either congenital or acquired funnel- 
front; but it is only a suggestion, for we must admit that as 
yet no very satisfactory or certain cause has been found. 



III. 

REPORT OF A CASE OF UNUSUAL CONGENITAL 
MULTIPLE DEFORMITIES. 

B. E. m'kENZIE, B.A., M.D., AND H. P. H. GALLOWAY, M.D., 

TORONTO. 

The patient, F. L., aged twenty years, whose photograj)h 
is shown in Figs. 1 and 2, was first examined about Jan. 1, 1900, 
The combination of congenital deformities which he presented 
was very unusual, if not unique; and this, together with the fact 
that the result of treatment was highly satisfactory, makes 
it seem desirable to place the case on record. 

The examination disclosed the following facts. There was 
congenital anterior dislocation of both hips. The right foot 
was an extreme example of talipes equino- varus. The left 
foot was greatly supinated and slightly in the equinus position. 
The left knee presented a combination of extreme knock-knee 
and genu recurvatum, so that it presented a salient angle look- 
ing backward and inward. Further, when the right knee was 
flexed, it bent laterally instead of antero-posteriorly, and the 
patella was at the outer side of the limb instead of in front, this 
being due to the outward rotation of the femur caused by the 
anterior dislocation. 

One would suppose that a patient the mechanism of whose 
lower extremities was so much out of gear would be almost 
incapable of locomotion; but, far from this being the case, he 
was fhirly active on his feet, and used neither cane nor crutches. 
We had frequently seen him on the street during several years 
before he was brought for examination, and had personally ob- 
served him playing ball with other boys, and appearing to 
enjoy the game. His mode of locomotion was, of course, ex- 
ceedingly awkward in appearance, enough so to be really painful 
to the lay observer; and the distortion was sufficiently hideous 
to affect unpleasantly persons of a sensitive temperament 



350 



COXGEXITAL MULTIPLE DEFORMITIES. 



who met him casually on the street. As he approached adult 
life, the humiliating nature of his condition made him anxious 
to secure relief; and he very willingly accepted the proposition 
that an improvement of his condition by surgical means be 
attempted. He was admitted to the Toronto Orthopedic 
Hospital, and on Jan. 12, 1900, the first operation was per- 




Fio. 1. 



formed. This consisted of subcutaneous section of the plantar 
fascia and of the tibialis anticus of the right foot, and of the 
plantar fascia, tibialis posticus, and the internal lateral liga- 
ment of the left foot, followed by forcible wrenching. The feet 
were then dressed in plaster of Paris in a greatly improved 
position. Eleven days later the left knee joint was excised, 
section of the bones being made in such planes that, when 
brought together, the outward rotation of the foot was cor- 
rected and the leg and thigh were in a straight line with the 



B. E. M'KEXZIE AND H. P. H. GALLOWAY. 351 

exception of about ten degrees of antero-posterior flexion at the 
level of the knee. At intervals of from three to six weeks the 
feet were forcibly manipulated under aniesthesia, the position 
being improved each time till the deformity was practically 
fully corrected. The varus and supination were over-corrected 
before making any attempt to correct the equinus, then by tenot- 




Fia. 2. 

omy of the tendo Achillis, followed by forcible manipulation, 
the equinus was overcome. After several months had elapsed 
the patient^s condition had been improved to a very gratifying 
extent; but locomotion was considerably impeded by the im- 
possibility of flexing the right knee antero-posteriorly, to which 
reference has already been made. To remedy this, a final 
operation, osteotomy of the right femur, was undertaken on 
July 19, six months from the time he first entered the hospital. 



352 CONGENITAL MULTIPLE DEFORMITIES. 

The shaft of the femur was cut through with a chisel at the 
junction of the middle with the lower third. The lower frag- 
ment was then rotated inward sufficiently to bring the patella 
in front, and in this position the limb was dressed in plaster 
of Paris. Sound union occurred in about two months, and 




Fio. 3. 

antero-posterior flexion of the knee was then possible (Fig. 3). 
In all the patient was anaesthetized eight times. The improve- 
ment in his appearance will be best appreciated by reference to 
the photograph reproduced in Fig. 3. He is earning his living 
as a clerk in a life insurance office, does not use even a cane; 
and, while locomotion is somewhat stiff and ungraceful, he can 
walk a distance of a mile or two without discomfort. 



IV. 

THE ELEMENT OF TORSION IN LATERAL CURVATURE 
OF THE SPINE: ITS PLACE IN THE CAUSE AND 
TREATMENT. 

(Third Paper,) 

ROBERT W. LOVETT, M.D., BOSTON. 

In spite of the present activity in orthopedic Hterature on 
the subject of rotary lateral curvature of the spine, our present 
knowledge of the mechanics of the affection is very inexact, 
and treatment for this reason is necessarily largely empirical. 
The explanations of the phenomena of scoliosis and the study 
of its mechanism have been written from a study of the espe- 
cial structure of the human spine, particularly the distorted 
scoliotic spine. The curves of the articular processes have 
been studied, the shape of the individual vertebrae has been 
analyzed, the physiological curves have been considered, and a 
large amount of work has been expended* upon this side of 
the question. This literature occupies a large space, but has 
proved of little practical value. 

The present paper is an attempt to study the element of 
torsion in its relation to lateral curvature, — a study not of the 
anatomy, but of the movements of the spine. 

The anatomical work was done at the Harvard Medical School, 
and the writer is indebted to Professor Thomas Dwight of the 
Harvard Medical School for his anatomical material and for 
the benefit of his criticism, to Professor I. N. HoUis of Harvard 
College for help on the mechanics of the problem, and to Dr. 
Henry Feiss of Cleveland for much help in the experimental 
part of the work. 

If one considers the human spine from the point of view of 

• Riedingrer, " Morpholo^ie und Mechaiiismus der Skoliose," Wiesbaden, 1901. 

Presented at the Seventeenth Annual Meeting: of the Association, Washingrton, 
D.Cm May 11-14. 1903. 



3,54 TORSION IN LATERAL CURVATURE. 

its evolution, one finds that the spinal column in its simplest 
form (Cyclostomata) consists of a homogeneous non-segmented 
flexible rod. The articular processes first appt»ar in some of 
the fishes (Rays and Teleostei), and are general in the Am- 
phibia (Gegenbauer). 

The spinal column in the lower fishes is a simple flexible rod 
consisting of a series of disc-like vertebra? bound together by 
intervertebral elastic discs without articular processes. Higher 
in the vertebrate group one finds elaboration of structure and 
the formation of permanent antero-posterior ("physiological") 
curves, along with modifications of the shape of the vertebne. 
But articular processes seem to have developed in the line of 
incidents rather than essentials, and in the higher forms to have 
carried out rather than radically modified the behavior of the 
simple fish's backbone, which is in mechanical tenns a straight, 
flexible rod. 

Articular processes in the human spine from the point of 
view of their evolution are therefore to be regarded as the re- 
sultants of use rather than as factors determining of them- 
selves the motions of the spine. They are the result rather 
than the cause of the behavior of the spine. 

The (luestions at issue are these: — 

(1) Why does rotation of the spine on its vertical axis occur 
in lateral curvature? 

(2) If lateral curvature is necessarily associated with ro- 
tation or torsion, may not the reverse be true, and may not 
rotation of the spine be necessarily accompanied by lateral 
curvature? 

On theoretical grounds Meyer came to the conclusion in 1865* 
that the articular processes were not the cause of torsion, but 
that torsion was due to the fact that the human spine was com- 
posed of two elements. — the column of bodies and the column 
of arches, — and that, as the two columns possessed a different 
degree of elasticity, side bending must result in a torsion, since 
these two elements of the column did not respond in the same 
degree to side bcndings. Since Meyer's view after long years 

• Meyer, Virch. Archiv, 1865, Bd. 35. 



ROBERT W. I.OVETT. 355 

of neglect has again come to the front,* it becomes of import- 
ance to examine the following aspects of the question : — 

(a) Do the articular processes determine or cause torsion 
of the spine? 

(6) Is torsion caused by the fact that the spine consists of 
two elements of different elasticity? 

(c) Does the spine as a whole behave as would a flexible rod 
of the same size and shape independently of the two factors 
mentioned above, and may not torsion be explained by this 
fact alone? 

In order to determine whether the articular processes cause 
torsion, and whether the united action of the two components 
of the human spine, the bodies and the arches, is necessary to 
produce torsion of the human spine in side bending, the follow- 
ing experiment was made: — 

The column of vertebral bodies was removed from an adult 
cadaver by cutting the pedicles of each vertebra, and the col- 
umn of vertebral bodies was observed by itself. In all respects 
it behaved as does the intact spine with ribs attached. Rota- 
tions and twistings followed the same formulae as in the flexi- 
ble rod and also the same formulae as in the intact human spine. 
Even the lack of torsion movement in the lumbar spine, sup- 
posed to be due to the close interlocking of the articular proc- 
esses, existed in the column of bodies, entirely independent of 
articular processes. 

This demonstrated that neither the articular processes nor 
the different elasticity of the bodies and arches was necessary 
for the production of torsion in side bending, but that such 
torsion occurred in the column of vertebral bodies alone, and 
that the column of vertebral bodies alone did not differ in its 
behavior from that of the intact human spine. 

Since, then, the whole spine behaves as w^ould the column of 
bodies alone, and since the history of the spine in its evolution 
is that of a flexible rod increasing in complexity of structure, 
an investigation was then commenced to see if the spine in its 
movements did not behave as would any flexible rod of similar 

•Albert, "Die Mechanismus der skoliotisclien Wirbelsaiile." Wien, 1899; Ried- 
in^er, " Morphologie uiid Mechanismus der Skoliose.'* Wiesbaden, 1901. 



356 TORSION IN LATERAL CURVATURE. 

size, shajDe, and elasticity. If such is the case, it would obey 
the laws of physics governing flexible rods; and as a passive 
instrument under certain conditions it must assume certain 
positions, and could not assume others so long as its structure 
was intact, just as a carriage will go backward or forward or 
may be turned to the right or left, but will not go up or down 
or sideways. It does not matter whether the carriage is pushed 
or pulled or goes of its own motive power, there are certain 
things that it can be made to do and others that it cannot be 
made to do, so long as its structure and equilibrium are intact. 
And, however much one carriage may differ in details from 
others, it is like every other so far as obeying certain general 
laws of physics. In the same way, spines may be grouped 
together in obeying certain physical laws, however much they 
may differ in detail. 

A flexible rod — as, for example, a quadrilateral rod of rubber 
— in bending or twisting follows certain definite mechanical 
laws; and these laws can be formulated in advance by any one 
familiar with mechanics. A straight flexible rod can be bent 
in one plane without twisting; but if such a rod, originally 
curved in one plane, be bent in another, it must twist. It must 
always do this, and can do nothing else. When the top is bent 
forward and to the right while the lower end is held, the front 
turns to the left, and always to the left. A fixed combmation 
of twisting and side bending exists for every position. 

From a mechanical point of view a pure twist may be pro- 
duced in a straight flexible rod without causing side displace- 
ment. There is a turning of each part of this rod in the hori- 
zontal plane, which is spoken of mechanically as shear, but no 
bending of the rod as a whole appears. But let this rod be 
bent already in the antero-posterior plane, and torsion of such 
a rod inevitably causes side displacement when viewed in the 
antero-posterior plane. 

This was demonstrated by experiment in a quadrilateral rod 
of sponge rubber one inch square and eight inches long and in a 
quadrilateral rod of lead thirty inches long. In the latter series 
of experiments the lower end of the rod was fixed in a vise and 



ROBERT W. LOVEIT. 



357 



the twist given by a monkey wrench at the free upper end. 
In both series of experiments a twist to the left was followed 
by one curve, and a twist to the right by the opposite curve. 
These results were constant in both series of experiments. 




Fio. 1. Composite Photograph of Cadaver. 

Straigrht and twisted to left. The white line is a strip of cotton cloth nailed to 
the spinous processes. The straigrht white line was before twisting: the curved 
white line to the right is the twisted position. 

The following experiments were undertaken on the human 
spine: — 

The spine of an adult of about forty and the spine of the 
cadaver of a boy eighteen years old were observed. The pelvis 



358 TORSIOX IN LATERAL CURVATURE. 

was firmly favStened to a box and the cer\'ical region twisted 
to the right and left by the hands and by a long brass rod fas- 
tened to the third dorsal vertebra. A lateral curv^e always 
accompanied the twisting, and occurred always to the left when 
the twisting was to the right, and to the right when the twist- 
ing was to the left. The curve was to the same side, and fol- 
lowed the same rules as that observed in the lead and rubber 
rods. 

Observ^ations were then made on the living model. The 
model was a woman of twenty-five, a professional model, who 
was' veiy flexible. With the pelvis fixed, active or passive 
twisting with the chin to the left produced a marked lateral 
curve to the right, with side displacement of the body to the 
right. T\visting to the right produced the opposite cur\^e. 
The curves were of the same character and followed the same 
rules as those observ^ed in the lead and rubber rods and the 
spine of the cadaver. In twisting with the chin to the left, 
the lateral curve begins at the dorso-lumbar junction and sweeps 
gradually out, returning in the cervical region to practically 
the median line. The lumbar region apparent!)^ takes little 
part in the lateral curve. It appeared at first as if there were 
a slight left lumbar cur\'e accompanying this right dorsal curve, 
but careful observation and measurement on the cadaver and 
model showed that there was but little, if any, lumbar lateral 
curve. There is but little movement of torsion in the lumbar 
vertebrae normally, so that in spines comparatively normal 
it can be readily seen that any phenomena of torsion wouUl 
be shown above rather than in this section of the spine. 

Torsion may be carried to a much greater degree in both model 
and cadaver when the spine is erect than when it is fully flexed. 
In the erect position 90° of rotation of the top of the column 
was possible in both, while in the flexed position only 45° was 
allowed. When t\Nisting is done in the position of full flexion 
of the spine, the lateral curve is located higher up than when 
it is done in the simple erect position; and its lower limit begins 
at about the seventh or eighth dorsal vertebra instead of at the 
dorso-lumbar junction. 



ROBERT W. LOVETT. 



359 



The backbone of a fish and the backbone of a cat when placed 
in corresponding positions behave in the same way as the rub- 
ber and lead rods, the living model and the human spine and 




Fig. 2.— Modkl Twisting to Left. 
Illustration from former paper. 



lateral bendings and torsion preserve the same relations to each 

other. 

The result, then, of these observations is as follows: — 

(1) An active or passive twist with the chin to the left in 

model and cadaver is accompanied by a dorsal curv^e to the 

right with displacement of the trunk to the right. In the erect 

position this lateral curv^ begins at the dorso-lumbar junction. 

In marked flexion the lateral curve begins at the seventh or 

eighth dorsal vertebra. 



362 TORSION IN LATERAL CURVATURE. 

to the pelvis. In all cases of lateral curvature observed by 
the writer, such a twisting has been found. In cases of what 
appear to be at first sight purely lateral postural curves, begin- 
ning scoliosis of the kind where no rotation is supposed to exist, 
one will find on looking down on the patient standing at ease 
that the shoulders are noticeably twisted with regard to the 
pelvis, and that one side of the shoulder girdle is carried forward 
and the other back. This is particularly noticeable in postu- 
ral cases after they have been standing for a minute or two 
and muscular fatigue has commenced. Such patients, if asked 
to bend fon\^ard until their trunk is horizontal (Adam's posi- 
tion), will appear to have no rotation or torsion present, and 
it will also disappear in recumbency or suspension; but, viewed 
from above in their natural standing position, it is evident. 
It may also be demonstrated by placing long pieces of splint 
wood horizontally against the sacrum and the back of the chest 
above the spines of the scapulae. This torsion is the inevitable 
outcome of every side yielding of the spine. But it is possible 
that the lateral curvature may have originated in a twist and 
that the side bending is secondary. 

If a child holds the head naturally twisted, as is often the 
case, from some inequality in the vision of the two ej^es or ui 
the acuteness of hearing in the two ears, or from some similar 
cause, the spine will inevitably be twisted. Again, the contact 
of the condyles of the occiput and the articular surface of the 
atlas is generally best when the head is held otherwise than 
quite straight, which is an established anatomical fact. The 
twisted position of children at school in consequence of im- 
proper school furniture is another factor leading to the acquire- 
ment of a twisted position of the spine. These factors all tend 
to induce a twist of the spine, and a twist of the spine must 
in all cases be accompanied by a lateral deviation, to the right 
if the twist is to the left, and a curve to the left if the twist is 
to the right. This etiological factor has been left lai-gely out of 
account in considering scoliosis. 

Since the association of torsion and side bending of the spine 
is a constant one, as has been seen in the preceding expeiiments. 



ROBERT W. LOVETT. 368 

it may be worth while to study scoliosis in terms of torsion. 
That is, to study the obliquity of the shoulders in a given case 
in the erect position to see whether the right or left shoulder 
is carried forward, and, knowing then the twist of the shoulder 
girdle with relation to the pelvis, to see with what lateral ciu^^e 
a right or left twist of the shoulder girdle is associated in the 
given case. In this way it is possible that some light may be 
shed on the origin of an individual case of scoliosis, and also 
possibly upon the general question of rotation. 

In a former paper the following conclusions were reached 
by a series of experiments on the spine of the human cadaver 
and on the living model:* — 

"Lateral bending, then, in both cadaver and model in posi- 
tion of marked flexion is accompanied by torsion, and this 
torsion is in this position always in one direction, and is of the 
same type as the rotation seen in scoliosis; that is, backward, 
on the convexity of the curve, or, in other language, the bod- 
ies of the vertebrae turn towards the convexity of the lateral 
curve. Various attempts were made to reverse this torsion 
while making side bendings in the flexed position by pulling 
the vertebrae apart, pressmg them together, etc., but in all 
cases in both cadaver and model the type of torsion described 
above persisted. ... In the intact spine of the cadaver, there- 
fore, and in the model, side bending in the extended position is 
accompanied by torsion of the vertebral bodies toward the 
concavity of the curve; in other words, the rotation is back- 
ward on the concavity of the curve, which is the reverse of the 
condition ordinarily seen in life in scoliosis." 

Proceeding in the light of this to investigate scoliosis, one 
finds that — 

(1) A simple postural curve, if acquired in the flexed posi- 
tion of the spine, will show a twist which may be predicted in 
advance. In such a curve to the left the left shoulder will be 
carried back and the right forward, because in such a curve 
the bodies of the vertebrae turn to the left, as shown in a former 
paper. 

*Loyett« ** Mechanics of Lateral Curvature/' Boston Medical and Swrgieal 
Joumah June 14, 1900. 



364 TORSION IN LATERAL CURVATURE. 

(2) If it is a curve originating in the extended portion of 
the spine, — that is, occurring in the lumbar region, — the twist 
will be reversed, and the right shoulder will be carried back. 

That cases of single postural curves commonly show a type 
of torsion that is the reverse of that seen in double curves has 
been noted clinically by Schulthess * and others (in one-third 
of the cases of total scoliosis, Jach.f). That is, in a left total 
curve the bodies of the vertebrae may turn to the right instead 
of toward the convexity of the lateral curve, which is to the left. 
This is explained by the existence of position (2) noted above. 
This in my experience seems to be the common type of torsion 
seen in the standing position in cases of total scoliosis of the 
postural type. 

(3) If the curve originates in a twisting of the spine rather 
than a side bending, the only twist observed that will cause a 
left curve is with the chin to the right, and therefore the right 
shoulder is back. 

In total left scoliosis, therefore, there are three conditions 
which make the shoulder girdle assume an obliquity with re- 
gard to the pelvis: — 

(1) A lateral curve to the left occurring in the flexed position 
of the spine with the left shoulder back. 

(2) A lateral curve to the left occurring in the extended por- 
tion of the spine with the right shoulder back. 

(3) A lateral curve to the left occurring as the result of a 
twisting of the spine with the face to the right, in which case 
the right shoulder is back. 

Three reversed conditions exist, of course, for right total 
curves. If one takes these six conditions and rearranges them 
in terms of right or left shoulder back, one may construct the 
following table for the interpretation of simple total curves: — 

If the right shoulder is back, it may be due to 

(1) Right total curve acquired in flexion. 

(2) Left total curve acquired in extension. 

(3) Left total curve from twisting to the right. 

•Schulthess, Zeitachr. f. orth. Chir., vol. vi. p. 380; Kiraiisson. Rev. d. Orth,, toI. 
vi. ; Hess. Zeitschr.f. orth. Chir., vol. vi. p. SK. 

t Zeitschr.f. orth. Chir,, 1892, l. 



ROBERT W. LOVETT. 305 

If the left shoulder is back, it may be due to 

(1) Left total curve acquired in flexion. 

(2) Right total curve acquired in extension. 

(3) Right total curve from twisting to the left. 

So far as the purely postiural cases of lateral curvatiue are 
concerned, the twist of the shoulders should be easy to decipher 
when the relations of torsion and side bending are understood. 
But in the severer cases of scoliosis, where there are two curves 
or even three curves, a new and confusing element, that of 
equilibrium or adjustment, comes in, which seems to have re- 
ceived little attention in the consideration of the mechanics 
of scoliosis. The element of equilibrium must modify the be- 
havior of the spine, because in addition to being a flexible rod 
it must be considered a flexible rod with a sense of balance and 
equilibriiun. Not only is there continually an instinctive at- 
tempt when in the upright position to keep the head in the 
middle line of the body over the base of support, but to keep 
the shoulders parallel to the pelvis and the head lookmg ap- 
proximately forward. 

Were it not for this instinct of adjustment, one would ex- 
pect that, as the lateral curve increased, the shoulders would 
twist more and more in their relation to the pelvis until in ex- 
treme cases of lateral curvature they might be twisted to an 
angle of 45° with the pelvis. Because, starting with a slight 
lateral curve, there would be a slight twist of the shoulders, 
and, with more lateral curve, a greater twist; but such is not 
the case. 

In cases of more advanced scoliosis the shoulders are also 
twisted in regard to the pelvis, but not very much more than 
in the beginning cases, yet the lateral curve is much greater. 
To go about with the shoulders twisted 45'' out of the lateral 
plane of the body would be an impossible condition; and, 
although in a slight lateral curve, the twist of the shoulders 
might be proportionate to the lateral element of the curve, 
it could not increase in the proper proportion as the lateral 
curve increased without resulting in an impossible and dis- 



366 TORSION IN LATERAL CURVATURE. 

abling condition. Consequently, somewhere between the shoul- 
ders and pehm some compensation has occurred; and the nat- 
ure and seat of this compensation constitutes one of the most 
intricate and perplexing problems in the question of lateral 
curvature. 

It would seem as if the twisting on a vertical axis shown in 
the prominence of the ribs on one side, known as the fixed ro- 
tation, in cases of scoliosis were the result of this compensation. 
The shoulders must be kept roughly parallel to the pelvis and 
the head looking approximately straight ahead. To accom- 
plish this parallelism of the shoulders and pelvis, compensat'mg 
twists (rotation) must occur in both lumbar and dorsal region; 
and they must be of an amount and character to keep so far 
as possible the top of the column pointing straight ahead. In 
the severe cases of right dorsal, left lumbar curve the left side 
will be prominent backward in the lumbar region, the right 
side backward in the lower dorsal region, but the axis of the 
shoulders again will be found backward on the left side. The 
instinctive sense of adjustment in keeping the atlas pointing 
in the same direction as the last lumbar vertebra is an impor- 
tant matter, demanding compensating twists in a colunm which 
has once seriously curved to the side. 

Rotation in severe lateral curvature, therefore, may be the 
result of the patient's instinctive efifort to keep -the shoulders 
square with the pelvis. A twist is necessitated by the beginning 
of every lateral curve, but this twist cannot carry the shoulder 
plane too far out of the pelvic plane. To get the shoulders 
back parallel to the pelvis, a compensating twist must be added 
to the existing twist, and the fixed rotation thus becomes the 
sum of the two. This is seen when one analyzes b}' the aid of 
the scheme furnished the condition where fixed rotation exists. 
The reading of the scoliosis in the light of the obliquity of the 
shoulders is not the same as in total curves of postural scoli- 
osis, but apparently the reverse. 

Fixed rotation is not, therefore, to be overcome by a simple 
untwisting, but must be regarded as a compound phenomenon 
induced by two twists, to be dealt with by local pressure in the 
usual wav. 



ROBERT W. IX)VETT. 307 

As to the therapeutic use of torsion of the whole spine, it is 
to be remembered that in the present treatment side bending 
and side pressure are practically the only unilateral or non- 
symmetrical movements used. Wullstein alone seems to have 
used torsion in forcible correction, but he has used it in con- 
nection with strong traction and as an accessory measure rather 
than to obtain its specific effect. Many complicated free 
standing movements involving torsion are used, because they 
seem to place the spine in an improved position; but such move- 
ments, when used, are purely empirical, and take but little 
account of the specific effect of torsion, which has never, so 
far as I know, been formulated or even studied from this point 
of view. Side bendings in the gjntnnastic treatment are of 
great value; but it must be remembered that side bending as 
such does not exist, but always carries torsion with it. The 
trend of modem gymnastic treatment of late years has been 
toward laying more stress on synunetrical exercises and less 
on active side bendings. 

The application of side force in the forcible correction of 
scoliosis has the theoretical and well-recognized objection that 
pressure must be communicated to the spine through the thorax. 
The ribs are movable at both ends, and a certain amount of 
force must be expended on the ribs before acting upon the spine. 
Torsion, on the other hand, acts directly upon the vertebra. 
Theoretically, it has this point of advantage. 

Torsion to the left with the spine erect causes, from the dorso- 
lumbar junction upward, a marked right dorsal curve, and the 
trunk is carried to the right of the median plane. If the spine 
is flexed before being twisted, the right dorsal curve begins 
higher up, at the seventh or eighth dorsal vertebra, and has the 
same character. Torsion to the right causes a left dorsal curve, 
which may be distributed through the whole dorsal region or 
located in its upper half, as may be desired. 

Moreover, it is by no means clear that many so-called post- 
ural cases of early lateral curvature do not have their origin 
in a twist of the whole spine rather than in a side bending, and 
that the apparent side bending is only the result of the twist. 



368 TORSION IN LATERAL CURVATURE. 

For such cases corrective twists would seem to be more rational 
treatment than corrective side bendings. 

The therapeutic application of torsion is therefore plain. A 
right dorsal curve should twist or be twisted to the right, which 
should curve the spine to the left. Should it be a high dorsal 
curve, the twist should be given in full flexion of the spine. So 
far as the writer's experience goes, the therapeutic problem 
has been worked out only with regard to cases without fixed 
curves, where it has seemed to have a proper application and 
a distinctly good eflfect. With regard to cases with fixed curves 
it is not possible as yet to say what is its therapeutic value. 

All that can be said at present is that torsion in the normal 
spine causes a distinct and uniform lateral curve, that postural 
cases of lateral curvature represent so slight a departure from 
the normal that rules governing the normal spine may be ap- 
plied to them, as has been demonstrated experimentally; that 
postural lateral curves may apparently originate in (a) the 
flexed position of the spine, (6) in the extended position of 
the spine, (c) in twisted positions of the spine in which the 
lateral curve is only symptomatic of the twist; that in these 
cases torsion movements and passive torsions are of thera- 
I)eutic value; and that, in general, the normal intact human 
spine behaves as would any flexible rod of similar curve, shape, 
and structure. 

It is to be hoped that a further knowledge of torsion may 
enable us better to understand severe cases of scoliosis with 
fixed curves, and it is not unlikely that torsion movements 
and forced torsion may be of use in the correction of such 
cases. 

DISCUSSION. 

Dr. A. B. JuDSON. — I made a statement some years ago to the effect 
that "a brace is powerless to reduce lateral curvature. Its i^plicatioo 
is injurious rather than beneficial" (Transactions, vol. ix. p. 205). I 
should have qualified this by saying that a brace applied to produce antero- 
posterior pressure would be useful in treatment, although not practically 
efficient for absolute reduction of the deformity, — ^an opinion that was 



DISCUSSION. 369 

especially maintained by our honorary member, Dr. Lee, in 1869 (Trans- 
actions of Pennsylvania State Medical Society, 1869, pp. 372-378). 

Such an application is called for on the ground that it would transfer 
weight from a part of the column which swings away from the median 
plane to a part which is held near the median plane because it is in the 
wall of the cavity. It is but a repetition of the mechanics involved in the 
application of pressure in a case of Pott's disease, in which we try to throw 
the weight on the sound part of the column. 

It does not seem to me to be necessary to go further, and to seek a jus- 
tification of this plan in the action of a column under lateral combined 
with antero-posterior curving, as I have tried to show in a recent paper 
on the subject (Transactions, vol. xiv. pp. 273-277). A column which 
curves antero-posteriorly, and at the same time laterally, may be said 
not to have two curves, but rather one curve partaking of antero-posterior 
and lateral qualities, — a simple curve produced by the resultant of two 
forces, one acting for antero-posterior and the other for lateral curving. 
Can it be said that this is necessarily attended by rotation, which is 
motion of an entirely different kind? Is it not simpler to say that this 
new movement comes from something extrinsic, — viz., the arrest or delay 
of lateral movement in one part, while another part is free to respond 
more widely to the curve-producing force? The questions involved are 
extremely interesting, and invite thoughtful study; and I think we are 
very much indebted to Dr. Lovett for calling attention to the subject in 
his usual thorough and pain.staking way. 

Dr. B. E. McKenzie said that the subject was a most complicated one, 
and he felt quite incompetent to follow the paper that had been read, — ^it 
would require a good deal of time for satisfactory mental digestion. The 
point just touched upon by Dr. Taylor, and which had been brought out 
in both of the papers read, — i.e., that the large lateral muscles of the 
abdomen had the power to produce lateral curvature, — ^was shown clini- 
cally in one very marked case which he had observed. The patient was 
a healthy, vigorous boy of eleven years, who had been taken ill with what 
was probably an anterior poliomyelitis. Some physicians had made a 
diagnosis of pseudo-hypertrophic paralysis, but the subsequent history 
proved this diagnosis to be incorrect. The paralysis affected very largely 
the abdominal muscles. Having been perfectly erect in the spine pre- 
viously, he developed very rapidly the most extreme ciu-vature in the 
lumbar region that the speaker had ever seen, the vertebrae in this region 
rotating about 90°, and the lateral masses projecting almost directly back- 
ward. The cause in this case could only be the loss of the staying power 
otherwise provided by the muscles as guys to hold the spine in position. 
He had imderstood Dr. Lovett to make certain statements regarding the 
spine with which he felt obliged to take issue, but on the spur of the 



370 TOR^SION IN LATERAL CURVATURE. 

moment it would be difficult to formulate objectioofi. He would con- 
gratulate Dr. Riely and Dr. Lovett on the apparatus presented. Both 
of them appeared to be simple in action and powerful. He was in the 
habit of dividing his work into two parts, — viz., (1) the application of 
force and (2) the training and educational value of gymnastics. Tlie use 
of applied fixtures of any kind, whether jackets or braces, he had almost 
absolutely given up, — a position that he had maintained for ten years. 
He thought as much force as the human spine could endure could be 
Applied by a simple method. If the patient were directly suspended by 
the arms, the latissimus dorsi muscles, having insertions near the shoulder 
and passing down to the crests of the ilia, became a continuous power from 
the hand to carry the weight of the pelvis and l^s. If the body be sus- 
pended entirely by the spine and a lateral force be applied by a girth 
around the body until the latter be drawn to an oblique position of 45° 
or 50°, great corrective force is exerted, and patients can sometimes have 
a weight of fifty pounds additional or even more. He thought that in 
this way the greatest amount of force could be applied. 

Dr. X. M. Shaffer said that from his studies of lateral curvature it 
seemed to him there were two classes of cases, one which had been very 
aptly described by the last speaker, and which he believed he had first 
described in 1876, — i.e., a lateral curvature due to poliomyelitis anterior, — 
and another class, in which there was, as in torticollis, an arrest of develop- 
ment on one side. In the first class the resulting deformity was exactly 
that which occurred in club-foot, for instance, where the lateral muscles 
were paralyzed and the posterior were in a normal state, but were con- 
tracting gradually. In the second class the patients grew about a cur- 
vature which became greater, not because the muscle shortened, but be- 
cause it did not grow. The greatly distorted shape of the bones in lateral 
curvature of the spine showed the amount of force involved in the pro- 
duction of lateral curvature. The upright position certainly could have 
nothing to do with this question : there was an element of growth against 
resistance, and in the direction of least resistance in nine-tenths of the 
cases of lateral curvature. In conmienting upon Dr. Lovett's paper, as it 
was being read, he said to one sitting near him that he had already devised, 
in an inveterate case of lateral curvature in the mid-dorsal region, an 
operation which consisted in producing a synostosis in the contiguous 
articular processes. Here was the keystone of the curve, and this op- 
eration would prevent a further increase in the curve. He expected this 
operation would be done in a few weeks. 

Dr. Wallace Blanchard said that the majority of cases of scoliosis seen 
by him were removed so far from the office and hospital that it was im- 
possible for them to come with sufficient frequency to make advantageous 



DISCUSSION. 371 

use of the scolitone. He thought the apparatus of Dr. Lovett met a de- 
cided want, as it was portable, could be supplied at a moderate cost, and 
possessed considerable and correctly applied power. 

Dr. Weigel said that one should bear in mind the fact that the amount 
of force applied, while efficient and capable of producing a marked change 
in the anatomical conditions, was made for a limited time only, so that 
the patient was subjected to a corrective influence for only a very short 
period in the twenty-four hours. He understood Dr. McKenzie to say 
that he had discouraged the use of supports in these cases. This seemed 
to him a question of very vital importance. In his own mind there was 
no question that a case of lateral curvature could be corrected to a cer- 
tain degree by the forcible methods, but in addition to this it was abso- 
lutety necessary to maintain the correction for every minute in the twenty- 
four hours. He believed it to be advisable to make a cast of the patient, 
and, after being corrected, to make a jacket over it, which will keep up 
all day, though perhaps in a modified form, the same kind of correction 
that was obtained by the forcible correction apparatus. This seemed to 
him a matter of the greatest practical importance. Dr. Weigel then pre- 
sented a cast which had been made from a patient in whom the curvature 
had progressed to about the third degree. A corrective jacket had been 
made which, he thought, must certainly exert an influence in maintaining 
a better static condition of the spine than could be done by any voluntary 
effort on the part of the patient. He had not found any great difficulty 
in having his patients come every day to the office for a sufficient time 
to secure whatever benefit was possible from systematic treatment by 
gymnastics and other corrective measures. 

His only object in presenting this paper jacket here again, the principle 
of which had been explained at the meeting at St. Louis in 1893, was be- 
cause some of the members said that they had not found it satisfactory. 
This was because it had been finished by them with shellac, but shellac 
was not waterproof. He had never recommended such finishing, but had 
advised the use of bath enamel. He had found, however, that this some- 
times chipped off, and hence he now had the jacket enamelled with five 
coats, and the enamel baked on. This was perfectly waterproof, and pos- 
sessed very considerable strength, so that it did not twist or get out of 
shape, if properly made. As compared with the aluminum jacket, it was 
about one-third lighter. 

Dr. RiDLON said that in his cases of bad lateral curvature requiring 
permanent support he had been in the habit of using Weigel's paper 
jackets. He had known them to last three years. 

Dr. Bradford said that the jacket was most useful, but required care 
in its use, and was expensive. He had been using a jacket made of sheet 



372 TORSION IX LATERAL CURVATURE. 

celluloid. This was easily moulded under boiling water, the hands heiDg 
protected by thick rubber gloves. In this way the celluloid was made 
hke soft leather, and could be moulded upon the cast. This made a very 
pretty jacket, which would ordinarily last a year, and sometimes would 
wear even for two years. 

Dr. LovETT, in reply to Dr. McKenzie, said that he had tried to make 
all the propositions in his paper plain, and he wished no one to accept 
them without demonstrating them to their own satisfaction. With re- 
gard to the method mentioned by Dr. McKenzie (of applying force in a 
right dorsal left lumbar curve, for instance) , if the patient were hung up 
by a strap over the right side of the chest and weights put upon the feet, 
he thought the lumbar curve would be uievitably exaggerated. Dr. 
Lovett showed a simple apparatus for home use in the forcible correction 
of lateral curvature. 



V. 
CLUB-FOOT STRETCHER. 

GWILYM G. DAVIS, PHILADELPHIA, PA. 

After a considerable experience in the straightening of 
club-feet by means of division of tendons and forcible manual 
stretching over Koenig^s block and the use of wrenches resem- 
bling those of Thomas and McCurdy, I became convinced of 
the desirability of possessing an implement with which I could 
apply any amount of force desired, in the direction desired, 
and with the least liability of injuring surrounding structures, 
such as the ankle joint and leg bones. 

Manual stretching, even over the block, was found ineffectual 
for very severe cases, unless carried to an extent which to me 
was unjustifiable. The persistent and repeated "maulings'' 
— I can find no more appropriate word — to which the foot was 
subjected endangered its integrity and even life. The use of 
WTenches necessitated a most careful application of the force 
and holding of the ankle to avoid tearing its ligaments or break- 
ing the bones of the leg. To overcome these objections, I took 
the two steel handles of the ostoclast that I exhibited before 
the American Orthopedic Association in 1899 (see Transactions), 
and fitted to them a foot-piece. The illustration shows the 
two handles united by a hinge at one extremity. On the upper 
is fastened a rubber pad. On the lower is a foot-piece which 
is slid along the bar and clamped at the desired place. The two 
supports for the heel and front portion of the foot can be sepa- 
rated to accommodate the size of the foot. It can be used for 
patients of all ages, and I have used it on infants as well as those 
of near adult age. In using it, the heel is placed on one support 
and the front of the foot on the other. The upper handle is 
then brought down on the arched instep or dorsum of the foot. 

Presented at the Seventeenth Annual Meeting of the Association, Washin^on, 
D.C.. May 11-14, 1903. 



374 



CLUB-FOOT STRETCHER. 



In this way, by two or three pressures, a severe case can be 
thoroughly stretched without excessive physical exertion. 

The amount of force used can be accurately controlled. If 
much is desired, the upper handle is placed beneath the axilla, 
while the lower one rests on the table. 

Any amount of force can be applied to the tarsus without the 
slightest fear of injuring the ankle or leg bones. 

In using it, I have frequently heard the ligaments crack, 
but have not broken even a metatarsal bone. The utmost 
damage done was in one case to split the skin of the sole for 
about an inch as the foot unfolded. This rent was closed with 
two catgut sutures, the foot placed in plaster, and primary 
union occurred. 




Cliil>-foot Stretrher, with enlarged view of the adjustable foot-piece. 



VI. 

THE TREATMENT OF INFANTILE SPASTIC 
PARALYSIS. 

E. H. BRADFORD, M.D. 

The treatment of this affection necessarily varies according 
to the extent of the disease, the age of the child, and the con- 
ditions surrounding the patient. AMiere idiocy is present, no 
treatment is practicable; but cases of impairment of the intel- 
lectual faculties often give the most satisfactory results in im- 
proving the patient's general condition and ability to move 
about and develop by the contact with a larger environment. 

In the earliest stages it may be recorded that the surgical 
problem of treatment is one of training of muscles. Leaving 
out of consideration in this paper any question of the pathology 
of the affection, when cases present themselves to the surgeon, 
they present a disability, owing to the patient's inability to 
control certain groups of muscles. A balance of muscular 
utility is necessary for muscular efficiency. This condition does 
not exist in infancy, and is a process of gradual training from 
infancy to adult life, and in skilled occupations even in adult 
life the requisite muscular skill depends upon constant training 
of the muscles. 

In spastic paralysis, owing to the central disturbance, obedi- 
ence to central voluntary effort varies. A condition of what 
may be termed muscular rebelliousness exists in certain nmscles 
and in the attempt at certain movements of the hand or foot. 
The child is in the condition of a circus driver of many horses 
which become tangled from inability to use the reins to each 
horse. If we can imagine the horses' reins varying in elasticity, 
the parallel will be more complete. It is necessary for the child 
not only to learn the connection between the mental effort and 
the muscular response, but to also learn the amount of effort 

Presented at the Seventeenth Annual Meeting^ of the Association, Wasliintfton, 
D.C., May 11-14. 1903. 



376 TREATMENT OF INFANTILE SPASTIC PARALYSIS. 

needed for certain groups of muscles which is greater than that 
which is needed for others. 

In cases which are at all advanced, the treatment is a double 
one, and consists not only in muscular co-ordination, but the 
stretching of the over-contracted muscles. In later cases still 
the prevention of the fibrous degeneration of muscles and the 
overcoming of existing hypertonicity of muscular groups are 
all factors in the problem. A typical case of a severe type will 




Severe Infantile Spastic Paralsrsis. 

present at an early age an inability on the part of the child to 
stand or even sit. There may or may not be disability of one 
of the hands; although a certain amount of intelligence exists 
in all cases which are capable of treatment, yet children with 
this affection are usually backward, partly from the central 
lesion and partly on account of the deprivation on the part of 
the child of the natural means of mental training by locomotion 
or association with other children. If the child attempts to 
walk, the hamstrings, adductor and calf muscles, are trained 
in a state of hypertonicity, and all locomotion is impossible. 
At this stage it is customary for the patient to submit to mas- 
sage and the application of electricity. It is doubtful if a suffi- 
cient amount of benefit is obtained by this treatment to justify 
the discomfort experienced by the child. In this early stage 
muscular training Ls of the greatest importance. Patients 



E. H. BRADFORD. 377 

should be stimulated to drag themselves or roll about in any 
possible way, and a gradual improvement will be observed if 
the child is under the care of a sensible nurse who will stimulate 
every effort of the child. 

The first mechanical arrangement which will be found of 
benefit in cases of this sort is usually a wheel crutch or a baby 
jumper. Benefit can be obtained in utilizing the child's natural 
tendency to use the arms in a pulling direction; and "exer- 
cisors" arranged as a rowing machine, or a trapeze or sloping 
ladder, can be all utilized to strengthen the child's muscles 
and foster a desire for activity. Children will be found to im- 
prove gradually even in the severer cases; and an excellent 
arrangement can be made at this stage by the employment of 
parallel bars placed close together and encouraging the child 
to walk, the hands placed upon the bars steadying the child, 
and the pressure of the bars against the hips answering for a 
similar purpose. 

When the child has reached the age of six to eight, the ques- 
tions of the use of apparatus or of operative procedures suggest 
themselves. The use of operative procedures alone, without 
any tenotomy, is inadvisable, in case the muscles are of any 
strength. Appliances usually add to the child's disability, and 
prevent his developing the necessary amount of muscular tram- 
ing. In some cases, however, light apparatus, such as a caliper 
appliance for the leg or light varus or valgus ankle supports, 
is of benefit. Usually, however, when children have reached 
the ages mentioned, the question of operative interference is an 
urgent one. The object of operative interference is of course 
to restore the balance of the muscles in such a way that the 
hypertonicity of one group of muscles may be corrected, enab- 
ling the overweighted opposing muscles to regain a chance of 
development. The muscular groups which need consideration 
in this particular are the adductors, hamstrings, and the calf 
muscles. Where a condition of equinus is present, simple tenot- 
omy is of the greatest benefit. It should be followed by fixa- 
tion of the limb in a corrected position, but not in an over- 
corrected position, as it is particularly important not to lengthen 



378 TREATMENT OF INFANTILE SPASTIC PARALYSIS. 

unduly the tendo AchillLs. After the retention of the plaster 
of Paris for a few weeks, the use of a light ankle support with 
the requisite check to undue extension of the foot is desirable 
for a few months, after which all apparatus should be discarded 
and massage employed. Where the hand muscles are divided, 




Distorted Brain in Case of Infantile Spastic Paralysis. 

tenotomy can be used; but it has seemed to the writer that an 
open incision gave the surgeon more accurate knowledge of the 
contracted tissues. The same is true where the adductors are 
hivolved. Only a small incision is needed. The tissues are 
retracted, and the shortened muscular septa can be divided by 
scissors. The limbs should be immediately kept straight by 
-a plaster of Paris bandage applied to the whole limb, and the 



E. H. BRADFORD. 379 

child placed upon a bed frame with, in case the adductors are 
shortened, adducting straps which will retain the child for a 
few days in a position of marked abduction of both limbs. 
After the wounds have healed, the child may be allowed to be 
lifted about, wearing caliper appliances with abducting straps 
at night. AH appliances can be laid aside in the course of a few 
months. 

Where, as is not infrequently the case, this condition exists 
in the upper extremity, operative measures of greater delicacy 
are needed. In a few instances a shortened condition of the 
pectoral muscle will be found to be present. The patient is 
unable to move the arm from his side. Where this is present, 
an incision over the shoulder and freeing completely the inser- 
tion of the j)ectoraIs upon the head of the humerus, followed by 
fixation of the limb in an outstretched position, will be followed 
by benefit. 

In the more common condition, however, the hand and fore 
arm are the parts which are chiefly affected. The hand assumes 
the well-known claw position, the fore arm is flexed at the 
elbow, and the hand is strongly pronated. Examination of 
this condition shows a contraction of the biceps, a contracted 
condition of the pronators and of the carpal flexors. The com- 
mon flexors of the fingers are usually only secondarily involved, 
and the condition which presents itself to the surgeon is the 
simplest means of overcoming the hypertonicity and contrac- 
tion of the above-mentioned muscles in such a way as to en- 
able the patient to utilize the hand. 

Forcible correction of the hand and arm under an anaesthetic 
and a retention for some time in this position has been recom- 
mended, but it would appear from practical experience that 
fasciotomy or myotomy in addition to the forcible correction 
will give better results. In the experience of the writer the 
division of the intermuscular septa enables the stretching of 
the fibres of the contracted muscles sufficient to restore the 
proper muscular balance without involving extensive dissection. 
Tenotomy of the muscles of the hand and fore arm has not seemed 
to the writer as beneficial as fasciotomy. 



380 TREATMENT OF INFANTILE SPASTIC PARALYSIS. 

Transplanting of the pronator radii has been done by the 
writer in three instances. In one of these the benefit of the 
procedure was marked: in the others, although a temporary 
benefit followed, the ultimate gain was not as great, perhaps 
owing to the difficulty of inserting the end of the pronator 
muscle in a proper position to enable it to act as a supinator, 
which was imusually great, owing to the shortened condition of 
the muscle. 

A great deal of benefit can be obtained in these simple opera- 
tions in the fore arm and in the hand. The writer has not 
foimd as much benefit from tendon transplantation as has been 
mentioned by some writers. The lengthening of the muscles by 
the division of the septa and intra-muscular fibrous bands, 
followed by over-correction, has been in several instances of 
marked benefit. It must, however, be clearly imderstood that 
these operations are simply a basis for careful muscular devel- 
opment and muscular training by use and exercises carefully 
suited to the patient. If these are not attended to, the bene- 
fit from the operation will be slight. 



VII. 

THE EARLY OPERATIVE TREATMENT OF TUBERCU- 
LOUS OSTEITIS OF THE KNEE. 

BERNARD BARTOW, M.D., BUFFALO, N.T. 

Except in raxe instances, when tuberculous disease of the 
knee begins on the tibial side of the joint, or in the periarticu- 
lar tissues, the initial lesion may be referred almost universally 
to the femoral epiphysis. The clinical signs of its presence in 
that part of the bone are indicated with reasonable clearness 
for a considerable period of time, before consecutive infection 
of the joint has taken place. The focal area may acquire quite 
sizable proportions, and the contours of the knee become much 
altered, before the suggestions of its epiphyseal location are lost 
in the gross infiltrations which attend the spread of the disease. 

Although not generally practicable immediately following the 
invasion of the epiphysis, to determine the site of the focus, the 
clinical phenomena at a little later period in the development of 
the disease point quite clearly to the inner condyle as its most 
frequent seat. This view is further re-enforced by the relatively 
greater exposure and frequency of trauma on that side of the 
articulation, as determining localization of infection. The knee 
joint is not immediately menaced by the presence of the disease 
in the epiphysis, and the search for the focal site may be de- 
ferred for quite a period of time with safety, as regards liability 
of its extension into the joint. 

This statement receives frequent corroboration, practically, in 
the earlier stages of the disease, during the employment of con- 
servative treatment. The motive for the very general recom- 
mendation of conservative treatment at that time depends, no 
doubt, on the fact of the focus being small and not in very close 
proximity to the articulation, and therefore pving rise to only 
a slight amount of reaction in the joint. By the temporary 

Pn»8ented at the Seyenteenth Annnal Meeting of the ABBociation, Washington, 
D.C., liay ll-M, tM3. 



382 TUBERCULOUS OSTEITIS OF THE KNEE. 

abolition of knee function in connection with this method of 
treatment, the encapsulation of the focus is greatly favored, and 
extension of infection retarded or occasionally arrested. Fail- 
ing, however, by measures directed to the restraint of the joint, 
to control the spread of the infective process in the epiphysis, 
the increase of disturbance referable to the inner condyle, and 
musculature, may be easily noted. These become still more 
evident in cases in which no restraint of knee fimction has been 
employed in the earlier months of the disease. In either in- 
stance the clinical signs are adequate for determining approxi- 
mately the part of the articular end of the bone which is in- 
volved, and the probable nearness of the focus to the articular 
surface. The s3mfiptomatology in this connection scarcely re- 
quires alluding to. The early reflex response of the muscles; 
the periosteal infiltration over the condyles, and the appearance 
of expansion or enlargement, especially of the inner condyle; 
and tenderness from digital pressure on the lateral aspect of the 
condyle, — are among the more important signs. Another phe- 
nomenon associated with the foregoing at a later period, and 
indicating the encroachment of the focus on the joint, is reaction 
inflammation in the periarticula